Select All That Apply Practice Test #5: Basic Care and Comfort

Correct answers (A, B, D):
A. Keep the head of the bed raised at least 30 degrees unless the provider orders otherwise.
B. Check tube placement as the facility policy directs, including the length marking where the tube leaves the nose.
D. Watch for and report bloating, nausea, vomiting or a firm, swollen abdomen.

Rationale: Aspiration of formula into the lungs can cause pneumonia. Raising the head of the bed at least 30 degrees, and often 30 to 45 degrees, helps keep formula moving down instead of up (A). A newly placed tube is confirmed by x-ray before the first use; after that the nurse checks placement as the facility policy directs, such as checking the length marking at the nose and the look of any aspirate, because tubes can slide out of place (B). Signs that the feeding is not tolerated, such as bloating, nausea, vomiting or a swollen abdomen, raise the aspiration risk and are reported (D). Policies on checking gastric residual volumes vary by facility. Option C is wrong because lying flat with the feeding running raises the risk of reflux and aspiration; if the client must be flat, the feeding is paused as the policy directs. Option E is wrong because blue dye is no longer used: it does not reliably detect aspiration and has been linked with harm.

Correct answers (A, C, E):
A. Guide the client through slow deep breathing or guided imagery.
C. Reposition the client with pillows for support and show how to splint the incision with a pillow when coughing.
E. Offer music the client chooses.

Rationale: Nondrug measures work best alongside prescribed pain medicine, not in place of it. Relaxation methods such as slow breathing and guided imagery lower muscle tension and anxiety (A). Supportive positioning and splinting the incision with a pillow reduce strain on the wound when the client moves or coughs (C). Music the client likes can reduce pain and anxiety (E). The nurse reassesses pain after each measure. Option B is wrong because distraction does not replace prescribed analgesia; undertreated pain after surgery makes it harder to cough, breathe deeply and walk, which raises the risk of complications. Option D is wrong because heat placed directly on a fresh incision, especially while the client sleeps and cannot report discomfort, can cause burns, and any heat or cold on a surgical site needs a prescription.

Correct answers (B, C, E):
B. Go to bed and get up at about the same times every day, including weekends.
C. Limit caffeine later in the day and avoid alcohol close to bedtime.
E. Keep the bedroom dark, quiet and cool, and put screens away before bed.

Rationale: Good sleep habits are the first step for most people with insomnia. A regular bedtime and wake time help set the body clock (B). Caffeine can keep people awake for hours, and alcohol may help people fall asleep but breaks up sleep later in the night (C). A dark, quiet, cool room and less screen light before bed make it easier to fall asleep (E). Option A is wrong because long or late naps reduce the drive to sleep at night; if a nap is needed, it should be short and early in the afternoon. Option D is wrong because the bed should be linked with sleep: if the client is still awake after what feels like about 20 minutes, it helps to get up, do something quiet in dim light, and return to bed when sleepy. The nurse also reviews medicines and health problems, such as pain or needing to urinate at night, that can disturb sleep.

Correct answers (A, C, D):
A. Tighten the pelvic floor muscles, hold, then relax, and repeat several times every day.
C. Cut back on caffeine and fizzy drinks, which can irritate the bladder.
D. Losing extra weight, if overweight, can reduce leaking.

Rationale: Stress incontinence happens when the pelvic floor muscles and urethral support are too weak to hold urine when pressure in the abdomen rises. Regular pelvic floor (Kegel) exercises strengthen these muscles and are a first-line treatment (A). The client finds the right muscles by imagining stopping the flow of urine, but should not practice by stopping urine midstream on a regular basis. Caffeine and fizzy drinks can irritate the bladder and increase urgency (C). Extra body weight puts pressure on the bladder, so weight loss often reduces leaking (D). Option B is wrong because cutting fluids too much makes urine concentrated, which irritates the bladder and raises the risk of constipation and urinary tract infection; spreading fluids through the day works better. Option E is wrong because incontinence is common but not a normal part of aging, and many people improve with exercises, bladder training and other treatments.

Correct answers (B, D, E):
B. Help the client into a normal position to urinate, such as standing or sitting on a commode, if allowed.
D. Give privacy, run water in the sink, or pour warm water over the perineum.
E. Check the bladder volume with a bladder scanner as the protocol directs and report the result.

Rationale: Anesthesia, opioids, pain, and lying flat can all make it hard to urinate after surgery. A normal position to void, such as a man standing or a woman sitting on a toilet or commode, uses gravity and feels more natural (B), as long as the client is safe to get up. Privacy, the sound of running water, and warm water poured over the perineum help the client relax the muscles that release urine (D). A bladder scan shows how much urine is in the bladder, and the result guides the next step under the provider's order or the facility protocol (E). Option A is wrong because catheter insertion needs an order or protocol and carries a risk of infection; simple measures and a bladder scan come first, and if a catheter is needed, an intermittent (straight) catheter is often used. Option C is wrong because limiting fluids does not fix retention and can cause dehydration.

Correct answers (A, B, E):
A. Place a cloth or cover between the pack and the client's skin.
B. Limit each application to the time set by the order or facility policy, and check the skin during treatment.
E. Take extra care with clients who have reduced feeling in the area or who are confused.

Rationale: Heat and cold can both injure the skin. A cover between the pack and the skin protects against burns and frostbite (A). Applications are kept to the time set by the order or facility policy, often around 20 minutes, and the nurse checks the skin for redness, blistering, pallor or numbness (B). Clients with nerve damage, such as diabetic neuropathy or a spinal cord injury, and clients who are confused or sedated may not feel or report harm, so they need closer checks (E). Option C is wrong because cold, not heat, is used early after a sprain: cold narrows blood vessels and limits swelling, while heat increases blood flow and can make swelling worse. Option D is wrong because lying on a heating pad traps heat against the skin and can cause a serious burn.

Correct answers (A, C, D, E):
A. Cool, mottled skin on the hands, feet and knees.
C. Changes in breathing, such as periods of no breathing that alternate with deep breaths.
D. Noisy, wet-sounding breathing from secretions in the throat.
E. Little or no interest in food or fluids.

Rationale: As death nears, blood flow moves away from the arms and legs, so the skin becomes cool and blotchy (mottled), often starting at the feet and knees (A). Breathing changes are common, including Cheyne-Stokes breathing, in which periods of no breathing alternate with deeper breaths (C). When the client can no longer swallow or clear secretions, breathing can sound wet or rattly (D); repositioning onto the side and prescribed medicines can help, and the family can be told this is usually not distressing to the client. The body's need for food and fluid drops, and the client loses interest in eating and drinking (E), so mouth care and moistening the lips keep the client comfortable. Option B is wrong because urine output decreases and the urine becomes darker as the kidneys slow down. The nurse also encourages the family to talk to the client, because hearing may continue until very late.

Correct answers (B, C, D):
B. Offer small, frequent meals of bland foods served cool or at room temperature.
C. Reduce strong smells in the room, such as food trays and perfume, and allow fresh air.
D. Provide mouth care after the client vomits.

Rationale: Small, frequent meals are easier to tolerate than large ones, and cool or room-temperature bland foods give off less smell than hot, greasy or spicy foods (B). Strong odors can trigger nausea, so removing meal tray covers away from the client, avoiding perfumes, and letting in fresh air help (C). Mouth care after vomiting removes the bad taste and protects the mouth, which is often sore during chemotherapy (D). Antiemetics are given as prescribed, often before treatment and before meals, rather than waiting until nausea is severe. Option A is wrong because large meals stretch the stomach and tend to make nausea worse. Option E is wrong because lying flat after eating can increase nausea and reflux; the client should sit up or rest with the head raised for a while after meals.

Correct answers (A, C, E):
A. Canned soup.
C. Deli or lunch meats.
E. Dill pickles.

Rationale: Most sodium in the diet comes from processed and prepared foods, not the salt shaker. Canned soups (A), deli and lunch meats (C), and pickled foods such as dill pickles (E) are usually very high in sodium. Lower-sodium versions exist, so the client learns to read the sodium content on food labels. The daily sodium limit is set by the provider for each client. Fresh fruit (B) and plain grains cooked without salt (D) are naturally low in sodium and are good choices. The nurse also reminds the client to check with the provider before using a salt substitute, because many contain potassium, which can be risky with some heart failure medicines and kidney problems.

Correct answers (B, C, D, E):
B. Make sure the weights hang freely and the ropes move smoothly through the pulleys.
C. Give pin site care as the facility protocol directs and watch for signs of infection.
D. Check color, warmth, movement, feeling and pulses in the affected leg on schedule.
E. Keep the client in good body alignment and let the client use an overhead trapeze to help move.

Rationale: Traction works only when the pull stays steady and in line with the bone. The weights must hang freely, and the ropes must run smoothly through the pulleys without knots or rubbing (B). The pins pass through the bone, so the pin sites are a path for infection; care follows the facility protocol, and redness, drainage, odor, fever or loose pins are reported (C). Swelling and pressure can damage nerves and blood vessels, so the nurse checks neurovascular status in the affected limb and reports changes (D). Good body alignment keeps the pull in the right direction, and an overhead trapeze, if allowed, lets the client move without disturbing the traction (E). Option A is wrong because resting or lifting the weights interrupts the pull, which can cause pain, muscle spasm and movement of the broken bone ends. Weights are not removed in skeletal traction unless the provider orders it.