Practice Basic Care & Comfort questions for the National Council Licensure Examination — RN. Every question includes a full explanation of why the correct answer is right and why the tempting distractors are wrong.
45 questions available · easy difficulty · NCLEX-RN · Free, no registration required
10 example questions with full explanations. Use the interactive practice above to work through the complete set.
Question 1hard
A nurse is caring for a mechanically ventilated patient in the ICU. The patient has a nasogastric tube in place for enteral feeding. Before initiating each intermittent tube feeding, the nurse checks gastric residual volume (GRV) and obtains 280 mL. The nurse should hold the feeding and notify the provider, as a GRV greater than 250 mL consistently indicates aspiration risk and mandates cessation of enteral nutrition.
Correct answer: B
This statement is false. While gastric residual volume monitoring is performed to assess tolerance of enteral feeding, a single GRV measurement of 250–500 mL does not automatically mandate permanent cessation of feeding. Current evidence-based guidelines (including ASPEN and SCCM recommendations) suggest that a GRV below 500 mL should not automatically result in holding tube feedings unless other signs of intolerance are present (e.g., abdominal distension, vomiting, discomfort). The nurse should re-check the GRV in 1 hour or per facility protocol, assess for signs of intolerance, and consider measures such as elevating the head of the bed 30–45 degrees and using prokinetic agents. Automatically stopping feedings for any GRV above 250 mL is an overly restrictive practice not supported by current guidelines and may lead to undernutrition.
Question 2hard
A postoperative patient who underwent a below-the-knee amputation reports phantom limb pain rated 7/10. The nurse applies a warm compress directly to the residual limb stump to provide non-pharmacological pain relief. This intervention is appropriate because heat promotes vasodilation, reduces muscle spasm, and is safe to apply directly to surgical stump sites in the immediate postoperative period.
Correct answer: B
This statement is false. Applying heat directly to a surgical stump in the immediate postoperative period is contraindicated. The residual limb is a fresh surgical wound with altered skin integrity, potential for poor circulation due to vascular compromise, and reduced sensation — all of which increase the risk of burns and thermal injury. Additionally, heat can increase localized swelling and bleeding risk at the wound site. Phantom limb pain arises from the central and peripheral nervous system reorganization, not from localized tissue injury, so local heat application to the stump would not address the underlying mechanism. Appropriate non-pharmacological interventions for phantom limb pain include mirror therapy, transcutaneous electrical nerve stimulation (TENS), desensitization techniques, and relaxation strategies.
Question 3hard
A hospice nurse is caring for an actively dying patient who has become unconscious and is exhibiting Cheyne-Stokes respirations. The patient's family asks the nurse to suction the loud gurgling sounds the patient is making. The nurse correctly explains that deep suctioning is indicated in this situation because it removes secretions causing the 'death rattle,' prevents aspiration pneumonia, and improves the patient's comfort in the final hours of life.
Correct answer: B
This statement is false. The 'death rattle' (noisy, gurgling respirations in a dying patient) results from pooled secretions in the posterior oropharynx and upper airway due to loss of the swallow and cough reflexes — not from lower airway secretions that suctioning could effectively reach. Deep suctioning in an actively dying, unconscious patient is not recommended because it does not improve the patient's comfort (the patient is typically unconscious and unaware of the sound), can cause significant distress, mucosal trauma, increased secretion production, and vagal stimulation. Current palliative care guidelines recommend repositioning the patient (lateral recumbent or semi-prone to facilitate passive drainage), administering anticholinergic medications (e.g., glycopyrrolate or hyoscine) to reduce secretion production, and providing family education that the sound is not distressing to the patient. The priority is comfort and dignity, not aggressive airway clearance.
Question 4hard
A nurse is caring for a postoperative patient who underwent a below-the-knee amputation. The patient is now 48 hours post-surgery and is hemodynamically stable. The nurse should position the residual limb in elevation continuously for the first 72 hours to prevent edema and promote healing.
Correct answer: B
This statement is FALSE. While elevating the residual limb for the first 24 hours post-amputation is appropriate to reduce edema, continuous elevation beyond 24–48 hours is contraindicated because it promotes hip flexion contracture, which would severely compromise the patient's ability to use a prosthesis. After the initial period, the limb should be kept flat and the patient should be positioned prone (if tolerated) to stretch the hip flexors. The nurse must balance edema management with contracture prevention — prioritizing long-term functional outcomes over short-term comfort measures.
Question 5hard
A nurse is caring for a mechanically ventilated patient in the ICU. The patient's oral care protocol includes application of chlorhexidine gluconate 0.12% solution to the oral mucosa every 12 hours. The nurse notices the patient's lips are dry and cracked. Using a standard petroleum-based lip balm to moisturize the lips is safe and appropriate for this ventilated patient.
Correct answer: B
This statement is FALSE. Petroleum-based products (e.g., Vaseline) are contraindicated for use on the lips or oral mucosa of mechanically ventilated patients because they are hydrophobic, can accumulate bacteria, and may be aspirated into the airways, increasing the risk of lipoid pneumonia and ventilator-associated pneumonia (VAP). The appropriate intervention is to use a water-based oral moisturizer specifically designed for critically ill or ventilated patients. Maintaining rigorous oral hygiene, including use of chlorhexidine and water-based moisturizers, is a core VAP bundle component and an important basic comfort and safety measure in the ICU.
Question 6hard
An ICU nurse is caring for an elderly patient who has been on mechanical ventilation for 6 days and has developed ICU-acquired delirium. Minimizing sedation, promoting a day-night cycle with natural light exposure, and encouraging early mobility are evidence-based nursing interventions that can reduce the severity and duration of ICU delirium, even in mechanically ventilated patients.
Correct answer: A
This statement is TRUE. The ABCDEF bundle (Assess, prevent and manage pain; Both spontaneous awakening and breathing trials; Choice of analgesia and sedation; Delirium assessment and management; Early mobility and exercise; Family engagement) is the current evidence-based framework for managing ICU-acquired delirium. Daily sedation interruptions (SATs), promoting circadian rhythm through light exposure and clustering of nighttime care, reorientation, and early progressive mobility — even in ventilated patients — have all been shown in multiple trials (including the MICU trial) to significantly reduce delirium duration, ventilator days, and ICU length of stay. Non-pharmacological, comfort-oriented interventions are first-line management for ICU delirium, making this an important intersection of rest/sleep care and patient safety.
Question 7easy
The nurse is caring for a patient with a urinary catheter. Which urinary output value over one hour should prompt the nurse to notify the provider immediately?
- A.20 mL/hr✓
- B.60 mL/hr
- C.35 mL/hr
- D.45 mL/hr
Correct answer: A
The minimum acceptable urinary output for an adult is 30 mL/hr. An output of 20 mL/hr falls below this threshold and indicates oliguria, which may signal inadequate perfusion, renal compromise, or hypovolemia, requiring immediate provider notification. Outputs of 35, 45, and 60 mL/hr are all within or above the acceptable range and would not require urgent action.
Question 8easy
A nurse is providing skin care for a patient who is immobile and incontinent of urine. Which intervention is most appropriate to prevent moisture-associated skin breakdown?
- A.Massage reddened bony prominences vigorously to increase circulation
- B.Apply a moisture barrier cream to the perineal area after each incontinence episode✓
- C.Leave the skin open to air to promote drying between episodes
- D.Use hot water when cleansing the perineal area to destroy bacteria
Correct answer: B
Moisture barrier creams protect the skin from prolonged contact with urine and feces, which can quickly break down the skin's protective acid mantle and lead to incontinence-associated dermatitis. Massaging reddened bony prominences is contraindicated because it can cause further tissue damage. Leaving skin open to air does not provide adequate protection against repeated moisture exposure. Hot water can burn and further damage already vulnerable skin.
Question 9easy
During morning care, the nurse is assisting a patient with a bath. Beyond hygiene, what is the primary nursing purpose of performing a head-to-toe assessment during bathing?
- A.To evaluate the patient's nutritional status based on body weight
- B.To document that the patient's hygiene needs have been met for the shift
- C.To provide an opportunity to identify new or worsening physical findings✓
- D.To determine whether the patient needs additional pain medication
Correct answer: C
Bathing provides the nurse with direct, full-body access to the patient, making it an ideal opportunity to detect changes such as new skin breakdown, bruising, edema, rashes, or wounds that might otherwise go unnoticed. While pain assessment and documentation are important, they are not the primary clinical purpose of integrating a physical assessment into bathing. Nutritional status is not evaluated through inspection during a bath.
Question 10easy
A nurse is caring for a patient who had an ileostomy placed two days ago. Which finding requires the nurse's immediate attention?
- A.The skin surrounding the stoma is moist after pouch removal
- B.The stoma protrudes slightly above the skin surface
- C.Liquid stool is draining from the stoma
- D.The stoma appears dark purple and dusky✓
Correct answer: D
A healthy stoma should be beefy red and moist, indicating adequate blood supply.Adark purple or dusky coloration suggests ischemia or necrosis of the stoma and requires immediate notification of the provider, as this is a surgical emergency.Aslightly protruding stoma is a normal and expected finding. Liquid output is expected from an ileostomy because the colon, which absorbs water, has been bypassed. Moist peristomal skin immediately after pouch removal is normal.