NCLEX-RN Basic Care and Comfort Summary

Pressure injuries happen when pressure cuts off blood flow to the skin, often over bones like the tailbone and heels. Turning the client at least every 2 hours (or more often if needed) relieves the pressure. Keeping the skin clean and dry, good nutrition, and pressure-relief mattresses also help.

Wrong choices

• "Massage reddened areas firmly" can damage tissue that is already injured.
• "Use a donut-shaped cushion" puts pressure on the ring around the area and reduces blood flow.
• "Keep the head of the bed at 60 degrees at all times" makes the client slide down, causing shear injury to the skin over the tailbone. Keep it at 30 degrees or lower when possible.

The cane is held on the strong (unaffected) side. For weakness in the left leg, the cane goes in the right hand. The client moves the cane forward at the same time as the weak left leg, then steps through with the strong right leg. This spreads the weight and gives the most support.

Wrong choices

• "Hold the cane in my left hand" puts the cane on the weak side, which gives less support and makes the client lean toward the weak side.
• "Move the cane forward after my right leg" is wrong. The cane moves with the weak leg, not the strong leg.
• "Lean the cane far out to the side" makes the client unsteady. The cane should be close to the body, about 15 cm (6 inches) to the side of the foot.

Sitting fully upright (about 90 degrees) helps food move down into the stomach and lowers the risk of food or liquid going into the lungs (aspiration). Clients often also tuck the chin slightly when swallowing, as taught by the speech therapist. The client should stay upright for a while after eating.

Wrong choices

• "Lying flat on the back" greatly raises the risk of choking and aspiration.
• "Reclining at 30 degrees" is not upright enough for eating safely.
• "Head tilted back" opens the airway and makes it easier for food to enter the lungs.

Assistive personnel can do routine, standard tasks for stable clients, such as measuring intake and output, bathing, feeding, and taking vital signs on stable clients. The nurse keeps responsibility for assessment, teaching, evaluation, and care of unstable clients.

Wrong choices

• "Assess a client's pain" is assessment, which is the nurse's job.
• "Teach a client how to use crutches" is teaching, which the nurse (or physical therapist) must do.
• "Help a client walk for the first time after surgery" needs the nurse, because the client's response is not yet known and the client may become dizzy or faint.

The drainage bag must stay below the level of the bladder. If the bag is raised, urine can flow back into the bladder and cause a urinary tract infection. The bag also should not touch the floor. The nurse should stop the AP and explain the correct position.

Wrong choices

• "Keeping the tubing free of kinks" is correct; kinks stop urine from draining.
• "Cleaning the skin around the catheter with soap and water" is correct routine catheter care.
• "Securing the catheter tubing to the client's thigh" is correct; it keeps the catheter from pulling and hurting the urethra.

Sudden coughing and trouble breathing during a tube feeding may mean the feeding is going into the lungs (aspiration) or the tube has moved. The first action is to stop the feeding so no more liquid can enter the lungs. Then the nurse keeps the head of the bed up, suctions if needed, checks oxygen level and breathing, and notifies the provider.

Wrong choices

• "Check the amount of feeding left in the stomach" can be done later. Stopping the feeding comes first.
• "Flush the tube with 30 mL of water" adds more liquid that could go into the lungs.
• "Lower the head of the bed" increases the risk of aspiration. The head of the bed should stay raised.

Bed rest slows blood flow in the legs, raising the risk of a blood clot in a deep vein (deep vein thrombosis, DVT). Swelling, warmth, redness, and pain in one leg are warning signs. A clot can break loose and travel to the lungs (pulmonary embolism), which can be deadly. The nurse should not massage the leg, should keep the client in bed, and should notify the provider right away.

Wrong choices

• "Reddened area that turns white when pressed" is blanchable redness, an early warning. It needs turning more often, but it is not an emergency.
• "A smaller appetite than usual" is common with bed rest and should be watched, but it is not urgent.
• "A small, hard bowel movement yesterday" shows a risk of constipation that needs care, but it is not life-threatening.

Going up stairs, the client steps up first with the strong (uninjured) leg, then brings up the crutches and the injured leg. Going down, the crutches and injured leg go first, then the strong leg. A simple saying is "Up with the good, down with the bad."

Wrong choices

• "Crutches and my right leg on the step first" is the method for going down stairs, not up.
• "Step up with my right leg first" puts weight on the injured leg, which the client cannot do.
• "Jump up with both feet" is unsafe and puts weight on the injured leg.

In the first 24 to 48 hours after a sprain, cold helps reduce swelling and pain by narrowing blood vessels. Ice should be wrapped in a cloth and used for about 15 to 20 minutes at a time, with breaks in between. Raising the ankle above heart level also helps.

Wrong choices

• "Put a heating pad on the ankle" increases blood flow and can make swelling worse right after an injury.
• "Soak the ankle in warm water" also increases swelling in a new injury.
• "Ice directly on the skin for 1 hour" can cause frostbite and nerve damage.

Fiber from fruits, vegetables, and whole grains, plus enough fluid, makes stool softer and easier to pass. Moving as much as possible and going to the bathroom when the urge comes also help. Clients with heart or kidney problems may have fluid limits, so they should follow their provider's advice.

Wrong choices

• "Take a laxative every day" can make the bowel depend on laxatives and is not a first choice for prevention.
• "Wait until it is convenient" causes stool to dry and harden, making constipation worse.
• "Drink less water" makes stool harder and constipation worse.