CSLB General Building (B) — All Questions

A nurse is caring for a client at risk for pressure injuries. Which intervention is most effective for prevention?

• a.Massage bony prominences vigorously
• b.Keep the head of the bed elevated at 90 degrees continuously
• c.Reposition the client at least every two hours✓
• d.Use a doughnut-shaped cushion for sitting

Repositioning at least every two hours relieves pressure over bony prominences and prevents skin breakdown. Massaging bony areas and doughnut cushions can cause tissue damage.

A client has a new order for a clear liquid diet. Which item is appropriate?

• a.Orange juice with pulp
• b.Cream of chicken soup
• c.Vanilla ice cream
• d.Apple juice and gelatin✓

Clear liquids are transparent and leave little residue, such as apple juice and plain gelatin. Pulp, cream soups, and ice cream are not clear liquids.

A nurse is assisting a client with dysphagia to eat. Which action promotes safe swallowing?

• a.Position the client upright and encourage chin-tuck swallowing✓
• b.Have the client lie flat while eating
• c.Offer thin liquids with a straw
• d.Encourage rapid eating to finish the meal

Sitting upright with a chin-tuck reduces aspiration risk in dysphagia. Lying flat, thin liquids, and rushing increase aspiration risk.

A nurse is providing oral care to an unconscious client. Which action is most important for safety?

• a.Place the client supine with the head flat
• b.Position the client side-lying to prevent aspiration✓
• c.Use large amounts of water to rinse thoroughly
• d.Insert fingers between the teeth to open the mouth

A side-lying position allows secretions to drain and prevents aspiration during oral care in an unconscious client. Minimal fluid and safe technique protect the airway.

A nurse is caring for a client with a nasogastric tube for feeding. What action best confirms placement before feeding?

• a.Auscultate air injected into the tube
• b.Place the tube end in water to check for bubbling
• c.Verify placement per facility protocol, often with pH testing or radiographic confirmation✓
• d.Ask the client if the tube feels correctly placed

Current standards rely on pH testing of aspirate and radiographic confirmation to verify tube placement. The auscultation and water-bubble methods are unreliable.

A client reports constipation. Which intervention should the nurse implement first?

• a.Administer an enema immediately
• b.Request a prescription for a stimulant laxative
• c.Restrict the client's oral intake
• d.Increase fluid and fiber intake and encourage activity✓

Nonpharmacologic measures such as increasing fluids, fiber, and activity are first-line for constipation. Enemas and laxatives are used when conservative measures fail.

A nurse is measuring a client's urine output through an indwelling catheter. Which finding should be reported to the provider?

• a.Urine output of less than 30 mL per hour for two consecutive hours✓
• b.Clear yellow urine of 60 mL over the past hour
• c.Slightly increased output after a diuretic
• d.Pale straw-colored urine

Urine output below 30 mL per hour may indicate inadequate renal perfusion or obstruction and should be reported. Clear, adequate output is a normal finding.

A nurse is assisting a client to use crutches on level ground. Where should the top of the crutch rest?

• a.Directly under the axilla for support
• b.About two finger-widths below the axilla✓
• c.At the level of the waist
• d.Against the mid-chest

Crutch tops should rest about two finger-widths below the axilla to avoid pressure on the brachial nerves, with weight borne on the hands. Resting on the axillae can cause nerve damage.

A nurse is caring for a client on bed rest. Which intervention prevents venous thromboembolism?

• a.Keeping the client's legs crossed for comfort
• b.Massaging the calves to relieve stiffness
• c.Encouraging leg exercises and applying sequential compression devices✓
• d.Placing pillows under the knees continuously

Leg exercises and sequential compression devices promote venous return and prevent clot formation. Crossing the legs, calf massage, and continuous knee flexion impede circulation.

A nurse is providing perineal care for a female client with an indwelling catheter. Which technique is correct?

• a.Clean from the anus toward the urethra
• b.Use the same cloth section for each stroke
• c.Apply powder around the catheter insertion site
• d.Clean from the urethra outward, away from the anus✓

Perineal care is performed from the cleanest area, the urethra, toward the anus to prevent introducing bacteria. A clean cloth section is used for each stroke.

A client is being repositioned to prevent complications of immobility. Which position best relieves pressure on the sacrum while maintaining alignment?

• a.The 30-degree lateral (side-lying) position✓
• b.Supine with the head of the bed at 90 degrees
• c.Prone position for extended periods
• d.High Fowler's position continuously

The 30-degree lateral position offloads the sacrum and trochanter while maintaining alignment. High Fowler's and prolonged supine positions increase shear and sacral pressure.

A nurse is caring for a client with a stage 2 pressure injury. Which description matches this stage?

• a.Intact skin with nonblanchable redness
• b.Partial-thickness loss of the dermis presenting as a shallow open ulcer✓
• c.Full-thickness loss with exposed bone
• d.Skin loss covered entirely by eschar

A stage 2 pressure injury is partial-thickness skin loss involving the dermis, appearing as a shallow open ulcer or blister. Nonblanchable redness is stage 1 and exposed bone is stage 4.

A client who is NPO reports a dry mouth. Which comfort measure is appropriate?

• a.Provide a large glass of water
• b.Give the client hard candy to suck
• c.Offer frequent oral care and moisten the lips✓
• d.Encourage the client to drink small sips of juice

For an NPO client, oral care and lip moisture relieve dryness without violating the NPO status. Providing water, candy, or juice would break the NPO order.

A nurse is applying antiembolism stockings. Which action is correct?

• a.Apply the stockings after the client has been up walking
• b.Roll the top of the stocking down for a snug fit
• c.Leave wrinkles in the stocking for flexibility
• d.Apply the stockings while the client is lying down before rising✓

Antiembolism stockings are applied before the client rises, while lying down, to prevent pooling of blood. Rolling the top or leaving wrinkles can create a tourniquet effect.