Activities Of Daily Living Assistance - NCLEX Pn

1. Which action is appropriate when assisting with oral care for an unconscious client?

   Side-lying position; use suction and avoid fluids pooling in mouth. Side-lying facilitates drainage, while suction and fluid control prevent aspiration in non-responsive clients.

2. What is the correct order for donning clothing for a client with one-sided weakness?

   Dress the affected side first; undress the affected side last. This sequence facilitates easier manipulation of clothing on the weaker side, reducing strain and promoting efficiency.

3. What is the most important action after retracting a foreskin for hygiene?

   Return foreskin to its normal position to prevent paraphimosis. Restoring the foreskin prevents constriction, swelling, and potential circulatory compromise.

4. What is the correct action if a client begins to fall during ambulation?

   Ease the client to the floor while protecting the head; call for help. Guided lowering protects vital areas, and seeking help ensures prompt medical response.

5. Which finding requires you to stop feeding and notify the nurse immediately?

   Coughing, choking, wet/gurgly voice, or respiratory distress. These symptoms indicate potential aspiration, requiring immediate intervention to ensure airway safety.

6. Which action best supports client autonomy during ADL care?

   Offer choices and allow the client to do as much as possible. Empowering clients through decision-making and self-performance enhances their sense of control and self-esteem.

7. What is the minimum time a client should remain upright after a meal to reduce aspiration?

   At least 30 minutes. Maintaining an upright position aids digestion and prevents reflux or aspiration of gastric contents.

8. Which item is most important to check before assisting a client into a shower chair?

   Ensure chair is locked/stable and the floor is dry and nonskid. Stability and dry surfaces prevent slips, ensuring safe transfers in wet environments.

9. What is the correct method to prevent injury when moving a client up in bed?

   Use a drawsheet and get assistance; avoid pulling on arms. Using proper body mechanics and tools avoids shear forces and joint injuries during repositioning.

10. Which action best prevents skin breakdown during bathing and drying?

    Pat skin dry and moisturize; avoid vigorous rubbing over bony areas. Gentle drying and hydration preserve skin integrity and prevent friction-induced damage.

11. Which instruction is correct for using a cane with a weak left leg?

    Hold cane in right hand; move cane with the left (weak) leg. Cane on the strong side provides balance, advancing with the weak leg for supported weight shift.

12. What is the priority nursing action when a client reports dizziness during a shower?

    Sit the client immediately and assess; do not leave the client alone. Immediate sitting stabilizes blood pressure, while assessment and presence prevent falls or injury.

13. What is the correct wiping direction for perineal care for an uncircumcised male client?

    From urinary meatus outward; retract then replace foreskin. This method minimizes infection by cleaning away from the meatus and ensures foreskin mobility.

14. What is the safest action when a client has dysphagia and pockets food in the cheek?

    Check the mouth between bites and after meals; remove pocketed food. Regular inspection prevents aspiration by removing retained food that could obstruct the airway.

15. What is the priority goal when assisting a client with activities of daily living (ADLs)?

    Promote safe independence while maintaining dignity and privacy. This goal encourages self-reliance, minimizes risks, and respects the client's rights and personal boundaries.

16. Which direction should you wipe during perineal care for a female client?

    Front to back (urethra to anus). This direction prevents contamination of the urinary tract with fecal bacteria, reducing infection risk.

17. Which position reduces aspiration risk when feeding a client?

    Upright at $90^\circ$ with head midline (chin slightly tucked). This position promotes effective swallowing and gravity-assisted food passage, minimizing choking hazards.

18. What is the correct principle for cleansing during a bed bath to reduce infection risk?

    Clean from cleanest to dirtiest areas. Progressing from least to most contaminated areas limits microbial spread and cross-contamination.

19. Which observation indicates TED stockings are too tight and require intervention?

    Cool toes, numbness/tingling, cyanosis, or delayed capillary refill. These signs suggest impaired circulation, necessitating removal to avoid tissue damage.

20. What is the correct technique to apply antiembolism (TED) stockings?

    Turn inside out to heel, place heel, then unroll; no wrinkles. This method ensures even compression, proper fit, and circulation without restricting blood flow.

21. What is the correct sequence for applying sterile gloves during perineal care?

    Sterile gloves are not used; use clean gloves for routine perineal care. Routine perineal care uses clean technique to prevent infection without necessitating sterile conditions.

22. What is the correct sequence for going down stairs with a cane?

    Down with the cane, then weak leg, then good leg. Leading with cane and weak leg ensures support, followed by the strong leg for controlled descent.

23. Which bed position is safest for giving a bed bath to reduce strain and protect privacy?

    Raise bed to working height and expose only the area being washed. Optimal height reduces caregiver back strain, and minimal exposure upholds client dignity.

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