NSG 3100: NCLEX Questions – Unit 1 |
100% Correct Answers & Rationales
The nurse is preparing to provide morning care to a client. What should the nurse
explain to the clients the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurse/client relationship
3. Moisturize the skin
4. Stimulate circulation - ---✔✔✔ANSWER----4. Stimulate Circulation
Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this
is not the most important purpose.
Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse/client
relationship but this is not the most important purpose.
Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but
this is not the most important purpose.
,Rationale 4: The three major reasons for a bath are to remove waste products such
as perspiration, stimulate circulation, and refresh the client.
The nurse is preparing to bath a client on the first postoperative day. Which nursing
intervention should take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath. - ---✔✔✔ANSWER----3.
Raise side rails when gathering supplies
Rationale 1: Applying lotion to the skin would be performed before or after, not
during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it is
not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This is a
safety issue, andsafety is second on Maslow's Hierarchy of Needs. The client is
only 1 day postop and may still besedated, posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during, the
bath and only with adoctors order.
, The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment
as appropriate for a client. What should the nurse select as an expected outcome for
this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment
3. The client, with supervision, will brush her teeth
4. The nurse will stress the importance of adequate fluid intake. - ---
✔✔✔ANSWER----3. The client, with supervision, will brush her teeth.
Rationale 1: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, naming the staff is not within the clients realm of
understanding.
Rationale 2: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, eliminating safety hazards is not within the clients realm of
understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth
but only with supervision. The client would not voluntarily brush her teeth without
prompting from the staff.
Rationale 4: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, stressing adequate fluid intake is not within the clients
realm of understanding.
The nurse is caring for a client with diabetes. What should the nurse include as foot
care for this client?
100% Correct Answers & Rationales
The nurse is preparing to provide morning care to a client. What should the nurse
explain to the clients the reason for a daily bath?
1. Assess skin integrity
2. Develop a nurse/client relationship
3. Moisturize the skin
4. Stimulate circulation - ---✔✔✔ANSWER----4. Stimulate Circulation
Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this
is not the most important purpose.
Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse/client
relationship but this is not the most important purpose.
Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but
this is not the most important purpose.
,Rationale 4: The three major reasons for a bath are to remove waste products such
as perspiration, stimulate circulation, and refresh the client.
The nurse is preparing to bath a client on the first postoperative day. Which nursing
intervention should take priority?
1. Apply lotion to the extremities.
2. Change the water when it becomes cold.
3. Raise side rails when gathering supplies.
4. Remove the soiled dressing during the bath. - ---✔✔✔ANSWER----3.
Raise side rails when gathering supplies
Rationale 1: Applying lotion to the skin would be performed before or after, not
during, the bath.
Rationale 2: Changing the water needs to be done before it becomes cold, but it is
not a priority.
Rationale 3: Raising the side rails would take priority when planning care. This is a
safety issue, andsafety is second on Maslow's Hierarchy of Needs. The client is
only 1 day postop and may still besedated, posing a risk for a potential fall.
Rationale 4: A dressing change would be performed before or after, not during, the
bath and only with adoctors order.
, The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment
as appropriate for a client. What should the nurse select as an expected outcome for
this client?
1. The client will be able to name the staff that works on the day shift.
2. The client will eliminate safety hazards in her environment
3. The client, with supervision, will brush her teeth
4. The nurse will stress the importance of adequate fluid intake. - ---
✔✔✔ANSWER----3. The client, with supervision, will brush her teeth.
Rationale 1: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, naming the staff is not within the clients realm of
understanding.
Rationale 2: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, eliminating safety hazards is not within the clients realm of
understanding.
Rationale 3: A client with cognitive impairment would be able to brush her teeth
but only with supervision. The client would not voluntarily brush her teeth without
prompting from the staff.
Rationale 4: Cognitive impairment limits the clients ability to understand and
comprehend; therefore, stressing adequate fluid intake is not within the clients
realm of understanding.
The nurse is caring for a client with diabetes. What should the nurse include as foot
care for this client?
