These questions are one of the NCLEX prep samples for Physiological Integrity. This post has a 25 set of questions with the accompanying answers and rationale located at the bottom. If you want to answer all of our NCLEX questions interactively then be one of our member today. Click here to join. It’s Free.
1. When assessing a toddler, age 18 months, nurse Sydney should interpret which of the following as a sign of a neurologic dysfunction?
a. Positive gag reflex
b. Positive tonic neck reflex
c. Positive Babinski’s reflex
d. Positive corneal reflex
2. A male client complains of severe abdominal pain. To elicit as much information as possible about the pain, nurse Richard should ask:
a. “Do you have the pain all the time?”
b. “Can you describe the pain?”
c. “Where does it hurt the most?”
d. “Is the pain stabbing like a knife?”
3. A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should:
a. start with the first voiding
b. start after a known voiding
c. always be with first morning urine
d. always be the last evening’s void as the last sample
4. A child, age 3, is hospitalized for treatment of Kawasaki disease. During the acute phase of this disease, nurse George must assess the child frequently for:
a. heart failure
b. kidney failure
c. desquamation of the hands and feet
5. During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. Nurse Tina should expect:
a. the client’s pupils to become dilated
b. the client to experience bronchodilation
c. a decrease in the client’s gastric secretions
d. a drop in the client’s heart rate
6. Nurse Abby is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the plan of care to reduce ICP?
a. Encourage coughing and deep breathing
b. Position with head turned toward side of brain tumor
c. Administer stool softeners
d. Provide sensory stimulation
7. A client has sustained a right tibial fracture and has just had a cast applied. Which instruction should nurse Melissa provide in his cast care?
a. Cover the cast with a blanket until the cast dries
b. Keep your right leg elevated above heart level
c. Use a knitting needle to scratch itches inside the cast
d. A foul smell from the cast is normal
8. Nurse Cecile is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:
a. restrict fluid intake to 1 qt (1,000 ml)/day
b. drink liquids only with meals
c. don’t drink liquids 2 hours before meals
d. drink liquids only between meals
9. While preparing a client for cholecystectomy, nurse Andrew explains that incentive spirometry will be used after surgery primarily to:
a. increase respiratory effectiveness
b. eliminate the need for nasogastric intubation
c. improve nutritional status during recovery
d. decrease the amount of postoperative analgesia needed
10. A client with heart failure has been receiving an I.V. infusion at 125 ml/hour. Now the client is short of breath and the nurse notes bilateral crackles, neck vein distention, and tachycardia. What should nurse Sharon do first?
a. Notify the physician
b. Discontinue the infusion
c. Administer a prescribed diuretic
d. Slow the infusion and notify the physician
11. A client who’s 24 weeks pregnant has sickle cell anemia. When preparing the plan of care, nurse Theresa should identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
a. Sedative use
12. A child is admitted to the pediatric unit with a serum sodium level of 118 mEq/L. Which nursing action takes highest priority at this time?
a. Replacing fluids slowly as ordered
b. Instituting seizure precautions
c. Administering diuretic therapy as prescribed
d. Administering sodium bicarbonate as prescribed
13. A client receiving thyroid replacement therapy develops the flu and forgets to take her thyroid replacement medicine. Nurse Princess understands that skipping this medication will put the client at risk for developing which of the following life-threatening complications?
b. Thyroid storm
c. Myxedema coma
d. Tibial myxedema
14. A client undergoes a total hip replacement. Which statement made by the client would indicate to nurse Rose that the client requires further teaching?
a. “I’ll need to keep several pillows between my legs at night.”
b. “I need to remember not to cross my legs. It’s such a habit.”
c. “The occupational therapist is showing me how to use a sock puller to help me get dressed.”
d. “I don’t know if I’ll be able to get off that low toilet seat at home by myself.”
15. A child, age 3, with lead poisoning is admitted to the facility for chelation therapy. Nurse Lisa must stay alert for which of the following adverse effects?
b. Fever and chills
d. Heart failure
16. Nurse Aubrey is assisting in developing a teaching plan for a client who’s about to enter the third trimester of pregnancy. The teaching plan should include identification of which danger sign that must be reported immediately?
b. Blurred vision
c. Dyspnea on exertion
d. Increased vaginal mucus
17. After total hip replacement, a client is receiving epidural analgesia to relieve pain. Which of the following is a nursing priority for this client?
a. Changing the catheter site dressing every shift
b. Assessing capillary refill time
c. Assessing for sensation in the legs
d. Keeping the client flat in bed
18. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. When planning this client’s care, nurse Melvin should include which intervention?
a. Increasing fluids to 2,500 ml/day
b. Teaching the client how to deep-breathe and cough
c. Improving airway clearance
d. Suctioning the client every 2 hours
19. An adolescent with well-controlled insulin-dependent diabetes mellitus has assumed complete management of the disease and wants to participate in gymnastics after school. To ensure safe participation, nurse Eve should instruct the child to adjust the therapeutic regimen by:
a. eating a snack before each gymnastics practice
b. measuring the urine glucose level before each gymnastics practice
c. measuring the blood glucose level after each gymnastics practice
d. increasing the morning dosage of intermediate-acting insulin
20. A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, nurse Ellen suspects that the child has:
a. patent ductus arteriosus
b. coarctation of the aorta
c. a ventricular septal defect
d. truncus arteriosus
21. Which nursing diagnosis takes highest priority for a client with hyperthyroidism?
a. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess
b. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing
c. Body image disturbance related to weight gain and edema
d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess
22. Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?
a. Imbalanced nutrition: Less than body requirements
b. Ineffective airway clearance
c. Impaired urinary elimination
d. Risk for injury
23. A preschool-age child underwent a tonsillectomy 4 hours ago. Which assessment finding would make nurse Jennifer suspect postoperative hemorrhage?
a. Vomiting of dark brown emesis
b. Refusal to drink clear fluids
c. Decreased heart rate
d. Frequent swallowing
24. A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for nurse Ashley to take would be to:
a. remove the raised skin because the blister has already broken
b. wash the area with soap and water to disinfect it
c. apply a weakened alcohol solution to clean the area
d. clean the area with normal saline solution and cover it with a gauze dressing
25. Which nursing action is most appropriate for a client hospitalized with acute pancreatitis?
a. Withholding all oral intake, as ordered, to decrease pancreatic secretions
b. Administering morphine, as prescribed, to relieve severe pain
c. Limiting I.V. fluids, as ordered, to decrease cardiac workload
d. Keeping the client supine to increase comfort