Basic Care and Comfort — NCLEX-RN practice questions

A client is being prepared for surgery and reports taking an herbal supplement, ginkgo biloba, regularly. Why is this important for the surgical team to know?

1. Ginkgo biloba has no interaction with anesthesia or surgery and may be continued as usual
2. Ginkgo biloba must be continued, because stopping it abruptly interferes with anesthetic metabolism
3. Ginkgo biloba can increase bleeding risk and is often recommended to be stopped before surgery
4. Ginkgo biloba affects only postoperative nutrition and appetite, not the operative course itself

Answer: C — Ginkgo biloba can increase bleeding risk and is often recommended to be stopped before surgery

C) Correct — ginkgo biloba can inhibit platelet function and increase bleeding risk, so providers often recommend discontinuing it before surgery. A) Incorrect — there is a recognized interaction. B) Not related to anesthesia mechanism. D) Understates the actual bleeding-risk concern.

Which newborn assessment finding would the nurse recognize as a sign of neonatal abstinence syndrome (NAS)?

1. Deep, calm sleep for prolonged periods between scheduled feedings
2. High-pitched cry, tremors, poor feeding, and hypertonicity
3. Bradycardia, hypotonia, and a weak, low-pitched cry
4. Delayed passage of meconium as the only abnormal finding

Answer: B — High-pitched cry, tremors, poor feeding, and hypertonicity

B) Correct — classic NAS presentation includes CNS irritability (high-pitched cry, tremors), poor feeding, and increased tone. A) NAS infants are typically hyperirritable, not calm/sleepy. C) NAS more often causes tachycardia and hypertonicity. D) Not a hallmark NAS sign by itself.

A 4-year-old is admitted with suspected epiglottitis: drooling, tripod positioning, muffled voice, and high fever. Which action is CONTRAINDICATED?

1. Keep the child calm and upright in the parent's lap
2. Prepare for possible emergency intubation
3. Use a tongue depressor to visualize the airway
4. Administer humidified oxygen as tolerated

Answer: C — Use a tongue depressor to visualize the airway

C) Correct (contraindicated) — a tongue depressor/throat inspection can trigger complete airway obstruction in epiglottitis; never attempted outside a controlled airway setting. A) Keeping the child calm in a position of comfort reduces the risk of triggering obstruction. B) Epiglottitis can progress to complete obstruction rapidly; the team must be ready to secure the airway. D) Supplemental oxygen is appropriate supportive care.

Which of the following are appropriate components of a comprehensive geriatric assessment? SELECT ALL THAT APPLY.

1. Functional status (ADLs/IADLs)
2. Cognitive screening
3. Medication review
4. Excluding social/family support from evaluation
5. Fall risk assessment
6. F) Nutritional status

Answer: ABCEF

Correct: A, B, C, E, F. A comprehensive geriatric assessment includes function, cognition, medications, falls, and nutrition. D) Wrong — social/family support is a critical component and should be included, not excluded.

Which nursing intervention is MOST important to prevent postoperative deep vein thrombosis (DVT) in a client after major surgery?

1. Maintaining strict bed rest for the entire recovery period to reduce strain on the surgical site
2. Avoiding all active leg movement to limit incisional pain and reduce the chance of dislodging a clot
3. Early ambulation, sequential compression devices, and prescribed anticoagulant prophylaxis as ordered
4. Applying tight, non-adjustable elastic bandages around both legs to compress the deep veins of the calf

Answer: C — Early ambulation, sequential compression devices, and prescribed anticoagulant prophylaxis as ordered

C) Correct — early ambulation, mechanical compression, and pharmacologic prophylaxis are evidence-based DVT prevention strategies. A) Prolonged bed rest increases DVT risk. B) Avoiding movement increases stasis/DVT risk. D) Overly tight, non-adjustable bandages can impair circulation.

Which finding in a surgical wound assessed on postoperative day 3 suggests a wound infection requiring provider notification?

1. Mild pink erythema confined to the incision edges, with no drainage, warmth, or change in reported pain
2. Increasing redness spreading beyond the incision, purulent drainage, fever, and increasing pain
3. A well-approximated, dry incision with intact staples and a small amount of serosanguineous crusting
4. Slight yellow-green bruising near the incision that is fading and non-tender to gentle palpation

Answer: B — Increasing redness spreading beyond the incision, purulent drainage, fever, and increasing pain

B) Correct — spreading erythema, purulent drainage, fever, and worsening pain together are classic signs of surgical site infection requiring prompt evaluation. A) Mild, localized erythema immediately post-op can be a normal inflammatory response. C) A normal, reassuring finding. D) Mild, expected bruising is common.

Which nursing action best supports functional independence for a frail older adult during a hospital stay?

1. Keep the client in bed with an indwelling Foley catheter in place to reduce fall and incontinence risk
2. Restrict visitors to reduce overstimulation and protect uninterrupted rest periods
3. Perform all ADLs for the client to conserve energy for physical therapy sessions
4. Encourage early, supervised mobility and minimize unnecessary tethers (lines, catheters)

Answer: D — Encourage early, supervised mobility and minimize unnecessary tethers (lines, catheters)

D) Correct — early mobility and minimizing unnecessary tethers reduce hospital-acquired deconditioning, delirium, and functional decline. A) Immobility and unnecessary catheters increase deconditioning, infection, and delirium risk. C) Performing all ADLs promotes dependence. B) Social engagement/family presence actually helps reduce delirium risk.

A nurse caring for a postpartum client notices heavy lochia with clots and a boggy fundus. The first intervention is:

1. Catheterize the bladder immediately, since a full bladder displaces the uterus and causes bleeding
2. Start an IV oxytocin infusion immediately, before assessing the fundus, to control the bleeding
3. Administer pain medication first so the client can tolerate the assessment and interventions that follow
4. Massage the uterine fundus until firm and re-assess; if no improvement, escalate per protocol

Answer: D — Massage the uterine fundus until firm and re-assess; if no improvement, escalate per protocol

D) Fundal massage is the immediate first-line intervention. A/B/C) Each follows or is wrong order.

Which intervention is MOST important when caring for a patient with a stage 3 pressure ulcer on the sacrum?

1. Massage the wound bed vigorously each shift to increase local circulation
2. Reposition every 2 hours and offload pressure from the affected area
3. Apply a heat source directly over the wound to promote blood flow and healing
4. Leave the wound open to air at all times so the surface can dry and scab over

Answer: B — Reposition every 2 hours and offload pressure from the affected area

Pressure ulcer prevention and healing both depend on offloading and frequent repositioning (q2h minimum). NEVER massage a wound — it shears tissue. Heat is contraindicated. Most pressure ulcers benefit from moist wound healing (covered with appropriate dressing), not open air.

Which teaching point is appropriate for the parent of a child recently diagnosed with celiac disease?

1. "Your child should follow a strict gluten-free diet, avoiding wheat, barley, and rye"
2. "A small amount of gluten occasionally is fine once the intestinal lining has healed"
3. "This condition requires no dietary changes, only enzyme supplements taken with meals"
4. "Only avoid gluten during symptomatic flares and resume a normal diet in between them"

Answer: A — "Your child should follow a strict gluten-free diet, avoiding wheat, barley, and rye"

A) Correct — strict, lifelong gluten avoidance is the cornerstone of celiac disease management. B) Even small amounts of gluten can cause intestinal damage. C) Dietary management is the primary treatment. D) Gluten avoidance must be consistent, not only during flares.

Refeeding syndrome?

Rapid drop in phosphate, potassium, magnesium when reintroducing nutrition after starvation — can cause cardiac arrest; refeed slowly and monitor electrolytes.

Postpartum hemorrhage?

Blood loss >500 mL vaginal or >1000 mL C-section. Most common cause: uterine atony. First action: massage fundus.

Restraint order requirements?

Time-limited order (adult: up to 4hr, renewed per facility policy). Least restrictive first. Assess q15-30min: circulation, skin, ROM, toileting.