Free NCLEX-RN Basic Care and Comfort questions
22 original Basic Care and Comfort questions on assistive devices, elimination, mobility / immobility, nonpharmacological comfort / palliative, nutrition and oral hydration, in Next Generation NCLEX formats.
- Practice mode is free; timed exam mode, at 2 minutes per question, comes with full access.
- Every answer has a rationale.
- For exam study only, not medical advice.
NCLEX-RN Basic Care and Comfort questions
- 22 questions
- Basic Care and Comfort
- 42 min in exam mode
- Practice mode, no timer
A short set from this test. We don't have free questions on that topic here yet, so this set mixes topics. Sets on a single topic are included with full access, so this set mixes topics. Take the full test instead
Or take all 22 questions:
Exam mode, with a timer like test day, is included with full access. See plans. Practice mode is free.
·
Questions are original practice items written to the published exam content, not real exam questions.
A client has been on bed rest for 4 days after abdominal surgery. The provider now prescribes ambulation. Which action should the nurse take first?
Correct answer: B
After days in bed, blood pools in the legs and the client is at risk for orthostatic hypotension: a systolic drop of 20 mm Hg or more, or a diastolic drop of 10 mm Hg or more, within 3 minutes of sitting or standing. Safety comes first, so every transfer or walk begins with dangling at the edge of the bed and checking for dizziness before standing.
- A Standing before a sitting check skips the step that detects dizziness and orthostatic hypotension while the client is still safe on the bed.
- B Correct: dangling for a few minutes lets the nurse check for dizziness or orthostatic hypotension before the client bears weight.
- C Walking comes later; a gait belt does not replace checking how the client tolerates sitting up first.
- D Walking alone after 4 days of bed rest is unsafe until the client's tolerance and need for help are assessed.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 13.3 Mobility: Applying the Nursing Process ·
A client has been immobile for 10 days after a stroke. For each assessment finding, indicate the body system in which the complication of immobility is occurring.
Cardiovascular Integumentary Musculoskeletal Gastrointestinal Right calf is red, warm, swollen and tender Intact skin over the sacrum has a red area that does not blanch Left foot rests in plantar flexion and cannot be brought to neutral Systolic blood pressure drops 24 mm Hg when the client sits up Last bowel movement 4 days ago; abdomen is distended Select one option in each row.
Correct answer: Right calf is red, warm, swollen and tender: Cardiovascular; Intact skin over the sacrum has a red area that does not blanch: Integumentary; Left foot rests in plantar flexion and cannot be brought to neutral: Musculoskeletal; Systolic blood pressure drops 24 mm Hg when the client sits up: Cardiovascular; Last bowel movement 4 days ago; abdomen is distended: Gastrointestinal
Immobility harms every system. Venous pooling causes clots (DVT) and orthostatic hypotension, pressure over bone causes pressure injuries, shortened tissue causes contractures and foot drop, and slowed peristalsis causes constipation. Sorting findings by system helps the nurse run a head-to-toe check on every immobile client.
- Right calf is red, warm, swollen and tender Cardiovascular: redness, warmth, swelling and tenderness in one leg suggest a deep vein thrombosis from venous pooling.
- Intact skin over the sacrum has a red area that does not blanch Integumentary: nonblanchable redness over intact skin is a Stage 1 pressure injury.
- Left foot rests in plantar flexion and cannot be brought to neutral Musculoskeletal: a foot fixed in plantar flexion is foot drop, a complication of immobility.
- Systolic blood pressure drops 24 mm Hg when the client sits up Cardiovascular: a systolic drop of 20 mm Hg or more with position change is orthostatic hypotension.
- Last bowel movement 4 days ago; abdomen is distended Gastrointestinal: slowed peristalsis leads to constipation, and abdominal distention is a related complication of immobility.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 13.3 Mobility: Applying the Nursing Process · Open RN Nursing Fundamentals 2e, 10.4 Pressure Injuries · MedlinePlus: Deep venous thrombosis ·
The nurse is planning care for a client who cannot turn without help. Which interventions help prevent complications of immobility? Select all that apply.
Select all that apply.
Correct answer: A, C, E
Regular turning, lifting with a draw sheet and two people, and supporting the feet prevent pressure injuries, shear and foot drop. Joint changes start within about 3 days, so range of motion begins as soon as possible. Long periods in high Fowler's or without turning add pressure and shear.
- A Correct: turning at least every 2 hours on a schedule relieves pressure and prevents skin breakdown.
- B High Fowler's around the clock increases pressure on the coccyx and encourages sliding, which causes shear.
- C Correct: two people and a draw sheet lift rather than drag the client, reducing shear and friction.
- D Joint changes can begin after 3 days of immobility, so range of motion should start as soon as possible.
- E Correct: positioning aids such as pillows and foot boots help prevent foot drop and contractures.
- F Skipping turns overnight leaves pressure on the same areas for hours and raises pressure injury risk.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
A client has a nasogastric feeding tube whose placement was confirmed by X-ray yesterday. Before giving a scheduled bolus feeding, which action is the best way for the nurse to check tube position?
Correct answer: C
X-ray confirms placement after insertion. After that, the nurse checks position every 4 hours and before every feeding or medication by comparing the visible tube length with the length documented at X-ray. If the length has changed or there is doubt, the feeding is held and placement is verified per policy.
- A The air 'whoosh' test is unreliable and should not be used to verify placement.
- B Judging aspirate by its appearance is unreliable and is not an accepted way to verify placement.
- C Correct: comparing the external length with the documented length is the recommended routine check before each use.
- D pH can support a check, but it should never be the only method used to confirm placement.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.5 Checklist for NG Tube Enteral Feeding by Gravity With Irrigation ·
For a client receiving continuous tube feeding, the nurse keeps the head of the bed at and checks tube position every hours. If the external tube length is longer than the documented length, the nurse should .
Choose the best option from each list to complete the sentence.
Correct answer: 30 to 45 degrees; 4; hold the feeding and verify placement
To reduce aspiration, the head of the bed stays at 30 to 45 degrees unless contraindicated, and tube position is checked every 4 hours and before each feeding or medication. A change in external length means the tube may have moved, so the feeding is held until placement is verified; if in doubt, an X-ray is obtained.
- 30 to 45 degrees is the recommended head-of-bed angle during tube feeding; lower angles raise aspiration risk.
- Tube position is checked every 4 hours and before every feeding or medication; waiting 6 or 24 hours leaves a migrated tube undetected for too long, and every 2 hours is more often than recommended.
- A changed length means the tube may be out of position, so the feeding is held until placement is verified rather than adjusted blindly or ignored.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Fundamentals 2e, 14.3 Nutrition: Applying the Nursing Process ·
The nurse reviews the 1200 note for a client receiving continuous tube feeding. Click to highlight the findings that require follow-up.
1200: Head of bed at . Client has had since 1100. External tube length is . Abdomen is ; bowel sounds . Client reports . Gastric residual volume . Skin at the nare .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: a new cough; 6 cm longer than the documented length; bloated; three loose stools this morning
A new cough and a change in external tube length both suggest the tube may be out of position and the client may be aspirating, so the feeding is held and the provider notified. Bloating and diarrhea are signs of feeding intolerance that are reported so the formula or rate can be changed. A residual under 500 mL with no other signs is not by itself a reason to stop.
- 40 degrees A head of bed at 40 degrees is within the recommended 30 to 45 degrees.
- a new cough Requires follow-up: new respiratory symptoms may signal aspiration; hold feedings until placement is verified.
- 6 cm longer than the documented length Requires follow-up: a longer external length means the tube may have moved out of the stomach.
- bloated Requires follow-up: abdominal bloating is a sign of feeding intolerance to report.
- present in all four quadrants Bowel sounds in all four quadrants are an expected finding.
- three loose stools this morning Requires follow-up: diarrhea is a sign of feeding intolerance to report to the provider.
- 150 mL A residual of 150 mL is well under 500 mL and, with no other signs, does not by itself call for stopping the feeding.
- intact without redness Intact skin at the nare is expected; the site is still assessed daily.
Learn this topic: How to give tube feedings safely: placement checks and aspiration prevention 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.3 Assessments Related to Enteral Tubes ·
The nurse reviews four clients who have new prescriptions for an indwelling urinary catheter. Which client has an appropriate indication for the catheter?
Correct answer: D
CDC-approved indications include urinary retention, hourly output monitoring in critically ill clients, selected surgeries, healing sacral or perineal wounds with incontinence, prolonged immobilization and end-of-life care. When a request does not meet an indication, the nurse contacts the provider and advocates for another approach.
- A Using a catheter in place of nursing care for incontinence is an inappropriate reason.
- B A client who can void should give a culture specimen without a catheter.
- C Prolonged postoperative use without an indication is inappropriate; catheters are removed as soon as possible after surgery.
- D Correct: hourly output monitoring in a critically ill client is a CDC-approved indication.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 21.3 Preventing CAUTI · CDC: CAUTI Guideline, Summary of Recommendations ·
The nurse is reviewing care for a client with an indwelling urinary catheter. For each action, indicate whether it is indicated or not indicated to prevent catheter-associated urinary tract infection (CAUTI).
Indicated Not indicated Keep the drainage bag below the level of the bladder and off the floor Clean the area around the urethra with antiseptic solution each shift Empty the bag into a separate clean container used only for this client Irrigate the catheter every day to keep it open Replace the catheter every 7 days on a set schedule Secure the catheter to the thigh to prevent movement Select one option in each row.
Correct answer: Keep the drainage bag below the level of the bladder and off the floor: Indicated; Clean the area around the urethra with antiseptic solution each shift: Not indicated; Empty the bag into a separate clean container used only for this client: Indicated; Irrigate the catheter every day to keep it open: Not indicated; Replace the catheter every 7 days on a set schedule: Not indicated; Secure the catheter to the thigh to prevent movement: Indicated
CAUTI prevention depends on a closed system, free urine flow, a low bag, clean emptying and a secured catheter. CDC does not recommend antiseptic periurethral cleaning, routine irrigation, or changing catheters at fixed intervals; routine hygiene during bathing and changes for clinical reasons are used instead.
- Keep the drainage bag below the level of the bladder and off the floor Indicated: a bag below the bladder keeps urine flowing away from the bladder; the floor contaminates it.
- Clean the area around the urethra with antiseptic solution each shift Not indicated: antiseptics are not used on the periurethral area while the catheter is in; routine hygiene is enough.
- Empty the bag into a separate clean container used only for this client Indicated: a separate clean container for each client prevents cross-contamination when emptying.
- Irrigate the catheter every day to keep it open Not indicated: routine irrigation is not recommended unless obstruction is expected.
- Replace the catheter every 7 days on a set schedule Not indicated: catheters are changed for clinical reasons, not at fixed intervals.
- Secure the catheter to the thigh to prevent movement Indicated: securing the catheter prevents movement and urethral traction.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: CDC: CAUTI Guideline, Summary of Recommendations · Open RN Nursing Skills 2e, 21.4 Inserting and Managing Indwelling Urinary Catheters ·
A client's indwelling urinary catheter was removed at 0800. At 1430 the client reports lower abdominal fullness and has been unable to void despite trying. A bladder scan shows 420 mL. Which action should the nurse take next?
Correct answer: A
After removal, the goal is a void within 6 hours. A client who cannot void or reports bladder fullness is checked with a bladder scan, and a retained volume over 300 mL is reported to the provider, who usually orders a straight catheterization. An indwelling catheter is avoided when possible to lower CAUTI risk.
- A Correct: 420 mL retained in a client who cannot void is urinary retention; a volume over 300 mL is reported to the provider, who typically prescribes straight catheterization.
- B More fluid adds to a bladder that already cannot empty and delays treatment of retention.
- C An indwelling catheter needs a prescription and is avoided when possible; straight catheterization is the usual order.
- D Being unable to void 6 hours after removal with 420 mL retained is not expected; it signals urinary retention.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 21.6 Removing an Indwelling Urinary Catheter · Open RN Nursing Fundamentals 2e, 16.5 Urinary Retention ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The nurse reviews the 0730 assessment. Click to highlight the findings that require immediate follow-up.
0730: Client is . Lung sounds: . External NG tube length . Abdomen . Urine . Temperature . SpO2 . Blood pressure . Sodium .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: coughing intermittently; crackles in the right lower lobe; 46 cm; 100.8°F (38.2°C); 91% on room air
The tube is 8 cm farther out than its X-ray-confirmed length, and the client now has a cough, crackles, a new fever and an SpO2 below 95%. Together these suggest the feeding may have entered the airway. Airway and breathing findings come first, so they need immediate follow-up; the abdomen, urine, blood pressure and sodium are within expected limits.
- coughing intermittently Requires follow-up: coughing in a client receiving tube feeding is a respiratory symptom that can signal aspiration.
- crackles in the right lower lobe Requires follow-up: crackles are adventitious sounds seen with pneumonia and fluid in the airways.
- 46 cm Requires follow-up: 46 cm is 8 cm longer than the 38 cm documented at X-ray, so the tube may have moved out of the stomach.
- soft with bowel sounds in all four quadrants A soft abdomen with bowel sounds in all four quadrants is expected.
- clear yellow, 40 mL/hr Clear yellow urine at 40 mL/hr meets the expected output of at least 30 mL/hr.
- 100.8°F (38.2°C) Requires follow-up: this is a new fever compared with 98.6°F the evening before.
- 91% on room air Requires follow-up: an SpO2 below 95% means oxygenation is compromised, and it has fallen from 97%.
- 132/78 mm Hg This blood pressure is close to the client's prior reading and needs no immediate action.
- 141 mEq/L Sodium 141 mEq/L is within the 135 to 145 mEq/L normal range.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 21.8 Applying the Nursing Process to Catheterization · MedlinePlus: Sodium blood test ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL For each finding, indicate whether it is more consistent with aspiration pneumonia or with a pressure injury.
Aspiration pneumonia Pressure injury Crackles in the right lower lobe Braden Scale score of 11 Head of bed found nearly flat while the feeding was running 3-cm area of nonblanchable redness over the sacrum Temperature 100.8°F (38.2°C) Respirations 24/min, up from 18/min the evening before Select one option in each row.
Correct answer: Crackles in the right lower lobe: Aspiration pneumonia; Braden Scale score of 11: Pressure injury; Head of bed found nearly flat while the feeding was running: Aspiration pneumonia; 3-cm area of nonblanchable redness over the sacrum: Pressure injury; Temperature 100.8°F (38.2°C): Aspiration pneumonia; Respirations 24/min, up from 18/min the evening before: Aspiration pneumonia
Being fed while not upright is a risk factor for aspiration, and fever, crackles and a rising respiratory rate are consistent with pneumonia. A Braden score of 12 or less means high pressure injury risk, and nonblanchable redness over intact skin is a Stage 1 pressure injury. Linking each cue to the right problem lets the nurse treat both.
- Crackles in the right lower lobe Aspiration pneumonia: crackles occur with pneumonia and fluid in the airways.
- Braden Scale score of 11 Pressure injury: a Braden total of 12 or less represents high risk for pressure injury.
- Head of bed found nearly flat while the feeding was running Aspiration pneumonia: being fed when not upright raises the risk of aspiration.
- 3-cm area of nonblanchable redness over the sacrum Pressure injury: localized nonblanchable redness over intact skin is a Stage 1 pressure injury.
- Temperature 100.8°F (38.2°C) Aspiration pneumonia: fever is a symptom of aspiration pneumonia.
- Respirations 24/min, up from 18/min the evening before Aspiration pneumonia: a rate above 20/min is tachypnea, which signals compromised breathing and fits a developing lung infection.
Learn this topic: How bed rest harms the body, and how turning and positioning prevent it 5-minute lesson
Source: MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Fundamentals 2e, 10.5 Braden Scale · Open RN Nursing Fundamentals 2e, 10.4 Pressure Injuries ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The client's priority problem is , most likely because .
Choose the best option from each list to complete the sentence.
Correct answer: aspiration pneumonia; the tube migrated and feeding ran with the bed flat
Use airway-breathing-circulation (ABC) priority: a problem that threatens breathing comes before skin or urinary problems. The tube is 8 cm out of its confirmed position and the feeding ran while the client lay nearly flat; now the client has a cough, crackles, fever and an SpO2 of 91%. Aspiration pneumonia, the most serious complication of tube feeding, is therefore the priority.
- By ABC priority, aspiration pneumonia comes first because it threatens breathing; the sacral injury is real but lower priority, urine is clear with adequate output, and no orthostatic data are given.
- A tube out of position plus feeding while not upright explains the new respiratory findings; the catheter, weakness and sacral redness do not.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · MedlinePlus: Aspiration pneumonia · Open RN Nursing Skills 2e, 10.3 Respiratory Assessment ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL For each potential nursing action, indicate whether it is indicated or not indicated for the client's care at this time.
Indicated Not indicated Stop the feeding pump until tube placement is verified Instill air through the tube and listen over the stomach Report the new lung findings and tube change to the provider Keep the head of the bed flat to take pressure off the sacrum Ask the provider whether the urinary catheter can be removed Increase the feeding rate later to make up the missed volume Select one option in each row.
Correct answer: Stop the feeding pump until tube placement is verified: Indicated; Instill air through the tube and listen over the stomach: Not indicated; Report the new lung findings and tube change to the provider: Indicated; Keep the head of the bed flat to take pressure off the sacrum: Not indicated; Ask the provider whether the urinary catheter can be removed: Indicated; Increase the feeding rate later to make up the missed volume: Not indicated
Safety and breathing come first: when respiratory signs suggest aspiration, feedings are withheld, the provider is notified, and placement is verified, usually by X-ray when in doubt. The head of the bed stays at 30 to 45 degrees. The catheter was placed for incontinence, which is not an appropriate indication, so the nurse also advocates for its removal.
- Stop the feeding pump until tube placement is verified Indicated: feedings are withheld until placement is verified when aspiration is suspected.
- Instill air through the tube and listen over the stomach Not indicated: the air 'whoosh' test is unreliable and should not be used to check placement.
- Report the new lung findings and tube change to the provider Indicated: respiratory symptoms that suggest aspiration are reported to the provider right away.
- Keep the head of the bed flat to take pressure off the sacrum Not indicated: a flat bed raises aspiration risk; the order is 30 to 45 degrees, and turning relieves the sacrum.
- Ask the provider whether the urinary catheter can be removed Indicated: incontinence alone is not an appropriate reason for an indwelling catheter, so the nurse advocates for removal.
- Increase the feeding rate later to make up the missed volume Not indicated: feeding stays on hold until placement is confirmed, and catching up on volume is not the current goal.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 21.3 Preventing CAUTI · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The nurse has notified the provider, who prescribes a portable X-ray to check the tube position. Which actions should the nurse take while waiting for the X-ray? Select all that apply.
Select all that apply.
Correct answer: A, D, E
When aspiration is suspected, feedings and medications are withheld until the X-ray verifies placement. Keeping the head of the bed raised lowers aspiration risk, and turning to the side relieves pressure on the sacrum while keeping the turning schedule. pH alone never confirms placement.
- A Correct: feedings are withheld until placement is verified.
- B Feedings and medications are withheld until placement is verified, because anything given through a misplaced tube can enter the airway.
- C pH can support a check but should never be the only method of confirming placement.
- D Correct: a head of bed at 30 to 45 degrees lowers the risk of aspiration.
- E Correct: the lateral position relieves pressure on the coccyx and sacral area, and turning every 2 hours prevents pressure injury progression.
- F The cough stopping does not confirm placement; feeding resumes only after the position is verified.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 17.5 Checklist for NG Tube Enteral Feeding by Gravity With Irrigation · Open RN Nursing Fundamentals 2e, 13.2 Mobility Basic Concepts · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
History
79-year-old client admitted 4 days ago with an ischemic stroke. Right-sided weakness; needs full assistance to turn. Speech-language pathologist found swallowing unsafe; client is NPO. A small-bore nasogastric (NG) feeding tube was placed on hospital day 2 and its position was confirmed by X-ray. External tube length documented after X-ray: 38 cm. An indwelling urinary catheter was inserted in the emergency department because the client was incontinent.
Orders
- Enteral formula 55 mL/hr by continuous feeding pump
- Water flush 30 mL through the feeding tube every 4 hours
- Head of bed 30 to 45 degrees
- Turn and reposition every 2 hours
- Indwelling urinary catheter to gravity drainage
Nurses' Notes
0500 (night nurse): Client found slid down in bed with the head of the bed nearly flat after a linen change. Feeding pump running. Client repositioned and head of bed raised.
0730: Client awake and follows simple commands. Coughing intermittently. Crackles in the right lower lobe. External NG tube length 46 cm. Abdomen soft; bowel sounds present in all four quadrants. 3-cm area of redness over the sacrum that does not blanch; skin intact. Braden Scale score 11. Catheter draining clear yellow urine, 40 mL/hr.
Vital Signs
Time Temperature Heart rate Respirations Blood pressure SpO2 Day 3, 2000 98.6°F (37.0°C) 84/min 18/min 138/82 mm Hg 97% on room air Day 4, 0730 100.8°F (38.2°C) 104/min 24/min 132/78 mm Hg 91% on room air Laboratory Results (Day 4, 0600)
Test Result Normal range White blood cell count 13,200/mcL 4,500–11,000/mcL Sodium 141 mEq/L 135–145 mEq/L Blood urea nitrogen (BUN) 17 mg/dL 6–20 mg/dL The next day, the tube is replaced, X-ray confirms its position, and the feeding is resumed. The indwelling urinary catheter was removed at 0800. For each finding, indicate whether it shows that care has been effective or not effective.
Effective Not effective SpO2 96% on room air; respirations 18/min External tube length matches the length documented after the new X-ray At 1500 the client has not voided; bladder scan shows 450 mL Head of bed at 35 degrees with the feeding running Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe Turning record shows position changes every 2 hours Select one option in each row.
Correct answer: SpO2 96% on room air; respirations 18/min: Effective; External tube length matches the length documented after the new X-ray: Effective; At 1500 the client has not voided; bladder scan shows 450 mL: Not effective; Head of bed at 35 degrees with the feeding running: Effective; Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe: Not effective; Turning record shows position changes every 2 hours: Effective
Normal oxygen saturation and respiratory rate, a stable tube length, a raised head of bed and a kept turning schedule show the plan is working. A rising fever with new crackles suggests the lung problem is worsening. Being unable to void 7 hours after removal with 450 mL retained is urinary retention, which is reported to the provider.
- SpO2 96% on room air; respirations 18/min Effective: SpO2 95 to 100% and respirations 12 to 20/min are within normal limits.
- External tube length matches the length documented after the new X-ray Effective: a length that matches the documented length suggests the tube has not moved.
- At 1500 the client has not voided; bladder scan shows 450 mL Not effective: the goal is to void within 6 hours, and a residual over 300 mL is reported to the provider.
- Head of bed at 35 degrees with the feeding running Effective: 35 degrees is within the 30 to 45 degrees that lowers aspiration risk.
- Temperature 101.3°F (38.5°C) with new crackles in the left lower lobe Not effective: rising fever and new crackles suggest worsening pneumonia.
- Turning record shows position changes every 2 hours Effective: turning at least every 2 hours follows the plan to prevent pressure injuries.
Learn this topic: How to care for an indwelling urinary catheter and prevent CAUTI 5-minute lesson
Source: Open RN Nursing Skills 2e, 10.3 Respiratory Assessment · Open RN Nursing Skills 2e, 17.2 Basic Concepts of Enteral Tubes · Open RN Nursing Skills 2e, 21.6 Removing an Indwelling Urinary Catheter · Open RN Nursing Fundamentals 2e, 16.5 Urinary Retention · Open RN Nursing Fundamentals 2e, 10.6 Integumentary: Applying the Nursing Process ·
A client with osteoarthritis of the left knee is learning to walk with a single-tip cane. Which statement by the client shows correct understanding of the teaching?
Correct answer: B
A cane is held in the hand opposite the weak or painful leg, and the cane and the weak leg move forward together so the cane takes some of the load off that leg. The handle should be at wrist level with the elbow slightly bent. On a step or curb, the stronger leg leads going up; going down, the cane is set on the lower level first and the weaker leg follows.
- A The cane goes in the hand opposite the weak leg, so this client should hold it in the right hand.
- B Correct: the cane and the weaker leg advance together, then the stronger leg steps past the cane.
- C Going up a step or curb, the stronger (right) leg leads and the cane and weaker leg follow.
- D The handle belongs at wrist level so the elbow is slightly bent; elbow height is too tall.
Source: MedlinePlus: Using a cane · Open RN Nursing Assistant, 8.5 Assisting With Ambulation ·
A speech-language pathologist recommends a food texture for a client with dysphagia that needs no biting or chewing, cannot be drunk from a cup and holds its shape on a spoon. Which IDDSI level matches this description?
Correct answer: D
The IDDSI framework has 8 levels: drinks run from Level 0 to Level 4 and foods from Level 3 to Level 7. Level 4 Pureed (Extremely Thick for drinks) is eaten with a spoon, cannot be drunk from a cup or sucked through a straw, needs no chewing and holds its shape. Level 3 still flows from a cup, and Levels 5 and 6 need some chewing.
- A Level 3 Liquidised can be drunk from a cup and does not hold its shape.
- B Level 5 Minced & Moist has small soft lumps and needs minimal chewing.
- C Level 6 Soft & Bite-Sized needs chewing before swallowing.
- D Correct: Level 4 Pureed needs no biting or chewing, cannot be drunk from a cup and holds its shape on a spoon.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: IDDSI: The IDDSI Framework · IDDSI: Complete IDDSI Framework Detailed Definitions 2.2 (2026) ·
A client with dysphagia after a stroke is prescribed IDDSI Level 5 Minced & Moist foods and Level 2 Mildly Thick drinks. Which actions should the nurse include in the client's meal plan? Select all that apply.
Select all that apply.
Correct answer: A, C, D
Aspiration precautions keep the client upright for meals (at least 45 degrees, as straight as possible) and for 30 to 45 minutes afterward, and use small bites of 1 teaspoon or less. The client gets only the prescribed textures: solids are not washed down with thin liquids, and mixed thin-thick foods such as cereal in milk are a choking risk. Talking while swallowing is avoided.
- A Correct: the client sits upright, at least 45 degrees and as straight as possible, while eating.
- B Washing solids down with sips of thin liquid is avoided unless the swallowing therapist approves, and thin liquids are not prescribed.
- C Correct: small bites of less than 1 teaspoon (5 mL) are easier to control.
- D Correct: the client stays upright for 30 to 45 minutes after eating.
- E Cereal in milk is a mixed thin-thick texture and a choking risk; the milk is also a thin liquid.
- F Talking and swallowing at the same time is avoided; caregivers are asked not to talk to the client while they eat.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: MedlinePlus: Swallowing problems · Open RN Nursing Assistant, 5.22 Skills Checklist: Preparing Clients for Meals and Assisting With Feeding · IDDSI: Complete IDDSI Framework Detailed Definitions 2.2 (2026) ·
A client admitted with a stroke passed a swallow screen yesterday and is eating lunch. The nurse reviews the lunch note. Click to highlight the findings that suggest a swallowing problem.
1215: Client is for lunch. after each spoonful of soup. after sips of the thickened juice. Tray . Voice sounds after swallowing. and has eaten 20% of the meal in 30 minutes. Temperature . Client is .
Click each part of the text to highlight it. Click again to remove the highlight.
Correct answer: Coughs; Clears throat repeatedly; wet and gurgly; Chews very slowly
Coughing or choking during or after eating, throat clearing after drinking, a wet or gurgly voice and slow chewing are signs of dysphagia, even in a client who passed an earlier screen. When they appear, the nurse stops the meal and notifies the provider so the speech-language pathologist can assess. A normal temperature does not rule out aspiration, which can be silent.
- sitting upright in a chair Sitting upright in a chair is the correct position for eating.
- Coughs Highlight: coughing during or after eating is a sign of a swallowing problem.
- Clears throat repeatedly Highlight: throat clearing after drinking is a symptom of dysphagia.
- matches the diet card A tray that matches the diet card is correct practice.
- wet and gurgly Highlight: a wet or gurgly voice during or after eating is a sign of dysphagia.
- Chews very slowly Highlight: slow chewing or eating is a symptom of a swallowing problem.
- 98.6°F (37.0°C) A normal temperature does not rule out aspiration, but it is not itself a sign of a swallowing problem.
- alert and follows commands Being alert and following commands is a reassuring finding.
Learn this topic: How nurses keep clients with swallowing problems safe, and which diet fits which client 5-minute lesson
Source: MedlinePlus: Swallowing problems · ASHA Practice Portal: Adult Dysphagia · Open RN Nursing Fundamentals 2e, 14.3 Nutrition: Applying the Nursing Process ·
The nurse needs to assess pain in a client with advanced dementia who can no longer communicate verbally. Which tool is most appropriate?
Correct answer: A
The Pain Assessment in Advanced Dementia (PAINAD) scale scores breathing, negative vocalization, facial expression, body language and consolability from 0 to 2 each, for a total of 0 to 10. It is designed for noncommunicative clients with advanced dementia. Self-report tools such as the 0–10 numeric scale and the FACES scale need the client to choose a rating.
- A Correct: PAINAD is a valid, reliable tool for noncommunicative clients with advanced dementia.
- B The numeric scale depends on the client's self-report, which this client cannot give.
- C With the FACES scale, the client chooses the face; the nurse does not pick one based on appearance.
- D The COMFORT Behavioral Scale is validated for children receiving mechanical ventilation.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.3 Pain Assessment Methods · Open RN Nursing Fundamentals 2e, 11.5 Comfort: Applying the Nursing Process ·
The nurse reviews comfort measures planned for clients on a medical unit. For each planned measure, indicate whether it is safe or unsafe.
Safe Unsafe Place a thin towel between an ice pack and the skin of a sprained wrist Leave a heating pad on a client's sore shoulder for 45 minutes Give a 3- to 5-minute back massage to a client with muscle tension Massage a client's red, swollen calf to ease the ache Check the skin under a cold pack every 5 minutes for a client who cannot speak Apply a warm pack over the site of an implanted pain pump Select one option in each row.
Correct answer: Place a thin towel between an ice pack and the skin of a sprained wrist: Safe; Leave a heating pad on a client's sore shoulder for 45 minutes: Unsafe; Give a 3- to 5-minute back massage to a client with muscle tension: Safe; Massage a client's red, swollen calf to ease the ache: Unsafe; Check the skin under a cold pack every 5 minutes for a client who cannot speak: Safe; Apply a warm pack over the site of an implanted pain pump: Unsafe
Heat is applied for 5 to 20 minutes and cold for no longer than 20 minutes, with a thin barrier such as a towel between the pack and the skin, and neither is placed over medication patches or implanted devices. If the client cannot communicate, the skin is checked every 5 minutes. A massage lasts about 3 to 5 minutes and is never given over red or swollen areas.
- Place a thin towel between an ice pack and the skin of a sprained wrist Safe: a thin barrier such as a towel prevents tissue damage from cold.
- Leave a heating pad on a client's sore shoulder for 45 minutes Unsafe: heat is applied for 5 to 20 minutes, depending on tolerance.
- Give a 3- to 5-minute back massage to a client with muscle tension Safe: a back massage of about 3 to 5 minutes relieves tension and soreness.
- Massage a client's red, swollen calf to ease the ache Unsafe: massage is never given over red or swollen areas.
- Check the skin under a cold pack every 5 minutes for a client who cannot speak Safe: for a client who cannot communicate, the skin under a heat or cold pack is checked every 5 minutes.
- Apply a warm pack over the site of an implanted pain pump Unsafe: heat and cold are not applied over medication patches or implanted devices.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.4 Pain Management · Open RN Nursing Assistant, 6.4 Comfort Measures ·
A client recovering from surgery set a comfort-function goal of 2/10 to do deep-breathing and coughing exercises. At 0900, before the exercises, the client rates pain 5/10. Complete the following sentences. The nurse and then reassesses the client's pain within . If the pain is still above the client's goal at reassessment, the nurse .
Choose the best option from each list to complete the sentence.
Correct answer: gives a prescribed intervention such as an analgesic or cold pack; 1 hour; takes further action, such as notifying the provider
A comfort-function goal is the pain level the client needs to reach to do recovery activities, here breathing and coughing exercises. When pain is above the goal, the nurse intervenes, for example with a prescribed analgesic, a cold pack or relaxation, and follows up within 1 hour (or a time frame based on the medication's route and onset). If the intervention does not work, more interventions are needed, which may include contacting the provider.
- Correct: pain above the goal calls for an intervention such as prescribed medication, cold or relaxation before the activity; waiting for the client to ask or canceling activity leaves the pain untreated.
- Correct: the nurse follows up within 1 hour to see whether the intervention worked.
- Correct: ineffective pain control requires follow-up interventions, which may include notifying the provider; the goal is not lowered or ignored.
Learn this topic: How nurses assess pain and relieve it with comfort measures beyond medication 5-minute lesson
Source: Open RN Nursing Fundamentals 2e, 11.3 Pain Assessment Methods · Open RN Nursing Fundamentals 2e, 11.5 Comfort: Applying the Nursing Process ·
Sign in to keep your progress on all devices. It's free.
Fix these topics first
Every topic
Your score by category
This is an estimate from a practice set. Official scores come only from the test maker.
About this NCLEX-RN Basic Care and Comfort practice test
- PracticePractice mode shows the answer after each question, with no timer. Timed exam mode comes with full access.
- Go at your paceYour answers save in this browser, so you can stop and come back later.
- Read your reportSee your score for each section, and why every answer is right or wrong.
- Fix weak spotsMissed questions go to your mistake book. Learn the topic, then try again.
What your score means
The real NCLEX-RN has no percent score. It is pass or fail.
The exam stops when it is 95% sure you are above or below the passing standard, or at 150 questions. So no practice percentage can predict a pass. Use your report to find weak categories.
Your score is the percent of points you earned. Some Next Generation questions give partial credit, scored the way NCSBN describes.
NCLEX-RN format
| Client needs category | Share of the exam |
|---|---|
| Management of Care | 15–21% |
| Safety and Infection Prevention and Control | 10–16% |
| Health Promotion and Maintenance | 6–12% |
| Psychosocial Integrity | 6–12% |
| Basic Care and Comfort | 6–12% |
| Pharmacological and Parenteral Therapies | 13–19% |
| Reduction of Risk Potential | 9–15% |
| Physiological Adaptation | 11–17% |
The exam has 85 to 150 questions in up to 5 hours, including 15 unscored pretest questions and three unfolding case studies. An on-screen calculator is provided.
Common questions
Are these real NCLEX questions?
No. These are original practice questions we wrote to the public 2026 test plan. They are not real exam questions.
Does this test stop early like the real NCLEX?
No. Ours has a fixed set of questions. The real exam is adaptive and can end anywhere from 85 to 150 questions.
How long does it take?
This set has 22 questions. Practice mode has no timer, so take as long as you need. With full access, exam mode gives you 42 minutes.
Can I stop and finish later?
Yes. Your answers save in this browser, so you can close the page and pick up where you left off.
Is this medical advice?
No. These questions are for exam study only.
Is it free?
Yes. No card. Start without an account; after 15 questions, a free account saves your progress. A paid plan unlocks all 717 verified NCLEX-RN questions, timed exam mode, sets on one topic and a score for every topic.