Basic Care and Comfort NCLEX-PN practice questions

Rationale

Playing personally familiar music from the resident's young adulthood at a low, comfortable volume is evidence-based for reducing dementia-related agitation; music encoded during formative years is often well-preserved in long-term memory, promotes emotional comfort, and decreases resistance during personal care. Option A: Documenting an intervention before it is performed constitutes falsification of the medical record; documentation must reflect care that has actually been provided. Option C: Imposing rigid time limits and behavioral expectations is counterproductive for clients with Alzheimer's disease; music therapy should be flexible and resident-centered, not directive. Option D: Loud, high-tempo, or unfamiliar music can increase sensory overstimulation and worsen agitation in clients with Alzheimer's disease rather than soothe them.

Answer: B

Rationale

Guided imagery combined with slow, deep breathing is a safe, evidence-based nonpharmacological technique for reducing pain perception. It requires no special equipment or separate order, carries no risk of wound harm, and is within the practical nurse's scope. The technique promotes relaxation, reduces anxiety that amplifies pain, and can be initiated immediately. Option B: Applying ice directly onto a surgical wound without a protective barrier is contraindicated and can cause skin and tissue damage; cold therapy near an incision requires a specific provider order and a protective covering. Option C: Lying supine with legs fully extended increases tension on the abdominal muscles and lumbar spine, worsening post-cholecystectomy discomfort; a semi-Fowler's position with knees slightly flexed reduces abdominal muscle strain and is far more appropriate. Option D: Massaging tissue directly around a surgical incision is contraindicated because it can disrupt wound closure, introduce microorganisms, and increase the risk of dehiscence.

Answer: A

Rationale

The Wong-Baker FACES Pain Rating Scale is validated for use in children ages 3 years and older. It uses facial expression drawings that a child can point to, making it developmentally appropriate for a 6-year-old who may not yet reliably manipulate abstract numbers. It is the standard self-report tool in pediatric ambulatory surgical settings. Option B: The Behavioral Pain Scale was developed for critically ill, intubated, or non-verbal adult patients in the ICU who cannot self-report. It is not validated for conscious, communicative pediatric patients and does not reflect this child's clinical picture. Option C: The McGill Pain Questionnaire requires reading comprehension and abstract vocabulary to choose from lists of descriptive pain adjectives; it is designed for literate adults and is entirely inappropriate for a 6-year-old child. Option D: The Numeric Rating Scale requires the child to abstract pain onto a 0–10 number line, a cognitive task typically reliable from age 8–9 and older. A 6-year-old is at risk of misinterpreting the scale, producing inaccurate pain scores.

Answer: A

Rationale

Inspecting the oral mucosa and checking denture fit is data collection within PN scope and directly addresses the resident's complaint of oral pain with chewing. Identifying the cause of poor intake (e.g., ill-fitting dentures, oral lesion) must precede any nutritional intervention so that the correct problem is reported to the RN and appropriate measures can be implemented. Option B: Substituting a liquid supplement may be appropriate eventually, but implementing it before identifying the underlying cause skips the assessment step and could mask a treatable problem such as a poorly fitting denture or oral infection. Option C: Documentation is appropriate but is not the first action; the PN must first collect data about the cause of pain and poor intake before reporting and documenting findings. Option D: Increasing fluid intake does not address the stated cause of reduced oral intake (mouth pain with chewing) and bypasses the necessary data-collection step.

Answer: A

Rationale

Cleansing with mild soap and water removes secretions and reduces infection risk at the insertion site. Patting the site dry prevents moisture accumulation that promotes skin breakdown and fungal growth. Rotating the external bumper (disk) daily prevents localized pressure necrosis at the skin surface. Inspecting the site for redness, drainage, or swelling is ongoing data collection within LPN scope and allows early identification of infection or buried-bumper syndrome. Option C: Applying any topical agent, including petroleum jelly, to a tube insertion site requires a provider order. Independent application is outside LPN scope, may promote maceration, and can mask signs of site complications. Option F: Removing or reinserting a PEG tube is a procedure outside LPN/LVN scope of practice. Any skin irritation should be documented and reported to the RN or provider for further evaluation and orders.

Answer: A, B, D, E