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. A male client arrives in the emergency department with an ice pick protruding from the loft lower abdominal quadrant. At this time, the best nursing action is to:
a. Immediately remove the object and apply firm pressure to the wound
b. Leave the object in place until the client is in the operating room
c. Establish a large bore IV line and then remove the object
d. Obtain the results of the STAT abdominal x-ray and then remove the object
2. To minimized the most common side effect of tetracycline therapy, nurse Jannie should instruct the client to:
a. Drink at least 2,00ml of fluid a day
b. Take medicine with a full glass of water
c. Take the medicine with milk or an antacid
d. Increase the intake of high fiber foods and roughage
3. Which of the following nursing measures would be effective in preventing aspiration in a post-tonsillectomy client?
a. Perform chest physiotherapy (CPT) every four hours
b. Suction the nasopharynx as needed
c. Place a bedside humidifier at the head of bed
d. Withhold all fluids until the client demonstrates a gag reflex
4. A client receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, nurse Marlyn notes the client is flushed, febrile, and having chills. To help establish a diagnosis of hemolytic transfusion reaction, the nurse should assess the client for:
a. Headache
b. Anxiety
c. Urticaria
d. Flank pain
5. A morbidly obese client is being prepared for a gastric reduction. Which of the following is most critical to include in the nurse’s care plan for this client?
a. Teaching coughing and deep breathing exercises
b. Identifying postoperative diet modifications
c. Discussing pain control measures
d. Teaching the proper techniques for ankle and leg exercises
6. In planning care for a client with a surgical wound healing by secondary intention, nurse Agatha can anticipate that the client will:
a. Have the wound sutured closed at a later date
b. Be at an increased susceptibility for infection
c. Require skin grafting for the wound to heal
d. Have well-approximated wound edges
7. To perform rescue breathing for an adult, nurse Hayden delivers one breath every:
a. 3 seconds
b. 4 seconds
c. 5 seconds
d. 6 seconds
8. Four hours after receiving transfusion with fresh frozen plasma (FFP), a client has repeat lab work drawn. Which of the following values should the nurse interpret to evaluate the client’s response to the transfusion?
a. Hematocrit
b. White blood cell count
c. Platelet count
d. Prothrombin time
9. A client with pneumonia is ordered to have chest physiotherapy )CPT) every four hours. In planning the client’s care, nurse Julius recognizes the purpose of chest physiotherapy (CPT) is to:
a. Stimulate the cough reflex
b. Encourage deep breaths
c. Dilate the bronchioles
d. Mobilize secretions in the airways
10. Nurse Kay checks the morning lab work on a client admitted with status asthmaticus. Which of the following results would suggest an allergic basis for the client’s illness, if the nurse noted it to be elevated on the white blood cell (WBC) differential?
a. Eosinophils
b. Lymphocytes
c. Monocytes
d. Neutrophils
11. Nurse Lovy is providing home care instructions to a client who has recently had a skin graft. It’s most important that the client remember to:
a. Use cosmetic camouflage techniques.
b. Protect the graft from direct sunlight
c. Continue physical therapy
d. Apply lubricating lotion to the graft site
12. Capillary glucose monitoring is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m., the client has a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Nurse Lester should expect the dose’s:
a. Onset to be at 2 p.m. and its peak to be at 3 p.m.
b. Onset to be at 2:15 p.m. and its peak to be at 3 p.m.
c. Onset to be at 2:30 p.m. and its peak to be at 4 p.m.
d. Onset to be at 4 p.m. and its peak to be at 6 p.m.
13. When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension. Nurse Ashley must notify the physician immediately because these findings may reflect which complication?
a. Shock
b. Encephalitis
c. Increased intracranial pressure (ICP)
d. Status epilepticus
14. A client received burns to his entire back and left arm. Using the Rule of Nines, nurse Sam can calculate that he has sustained burns on what percentage of his body?
a. 9%
b. 18%
c. 27%
d. 36%
15. When administering spironolactone (Aldactone) to a client who has had a unilateral adrenalectomy, nurse Walter should instruct the client about which of the following possible adverse effects of the drug?
a. Breast tenderness
b. Menstrual irregularities
c. Increased facial hair
d. Hair loss
16. Dr. Samson prescribes didanosine (ddI [Videx]), 200 mg P.O. every 12 hours, for a client with acquired immunodeficiency syndrome (AIDS) who is intolerant to zidovudine (azidothymidine, AZT [Retrovir]). Which condition in the client’s history warrants cautious use of this drug?
a. Peripheral neuropathy
b. Diabetes mellitus
c. Hypertension
d. Asthma
17. After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client’s immediate needs, then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, this examination must be brief but should include:
a. Evaluation of the corneal reflex response
b. Examination of the fundus of the eye
c. Assessment of the client’s gait
d. Evaluation of bowel and bladder functions
18. Two weeks ago, a client underwent repair of an abdominal aortic aneurysm. Now she has several postoperative complications, including wound infection and failure to wean from the ventilator. While suctioning the client, the nurse notes that her sputum is copious, foul-smelling, and green-tinged and sends a specimen for culture and sensitivity testing. When the test results indicate a Pseudomonas aeruginosa, infection, Dr. Gutierrez prescribes gentamicin sulfate (Garamycin), 80 mg I.V. every 8 hours. Nurse Paul should infuse this drug over at least:
a. 5 minutes
b. 10 minutes
c. 20 minutes
d. 30 minutes
19. A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which of the following interventions should nurse Anne perform to assist the client?
a. Assure the client that everything will be all right and that he shouldn’t become upset
b. Ask a family member to interpret what the client is trying to communicate
c. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk
d. Ask the client to write, use a picture board, or spell words with an alphabet board
20. Nurse Rhea is teaching a client how to irrigate his stoma. Which action indicates that the client needs more teaching?
a. Hanging the irrigation bag 24″ to 36″ (60 to 90 cm) above the stoma
b. Filling the irrigation bag with 500 to 1,000 ml of lukewarm water
c. Stopping irrigation for cramps and clamping the tubing until cramps pass
d. Washing hands with soap and water when finished
21. Dr. Santos prescribes glipizide (Glucotrol), an oral antidiabetic agent, for a client with type 2 diabetes mellitus who has been having trouble controlling the blood glucose level through diet and exercise. Which medication instruction should the nurse provide?
a. Be sure to take glipizide 30 minutes before meals
b. Glipizide may cause a low serum sodium level, so make sure you have your sodium level checked monthly
c. You won’t need to check your blood glucose level after you start taking glipizide
d. Take glipizide after a meal to prevent heartburn
22. A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic indicates myocardial ischemia?
a. Prolonged PR interval
b. Absent Q wave
c. Elevated ST segment
d. Widened QRS complex
23. A client undergoes hip-pinning surgery to treat an intertrochanteric fracture of the right hip. Nurse Andrew should include which intervention in the postoperative plan of care?
a. Performing passive range-of-motion (ROM) exercises on the client’s legs once each shift
b. Keeping a pillow between the client’s legs at all times
c. Turning the client from side to side every 2 hours
d. Maintaining the client in semi-Fowler’s position
24. When preparing a client, age 50, for surgery to treat appendicitis, the nurse formulates a nursing diagnosis of Risk for infection related to inflammation, perforation, and surgery. What is the rationale for choosing this nursing diagnosis?
a. Obstruction of the appendix may increase venous drainage and cause the appendix to rupture
b. Obstruction of the appendix reduces arterial flow, leading to ischemia, inflammation, and rupture of the appendix
c. The appendix may develop gangrene and rupture, especially in a middle-aged client
d. Infection of the appendix diminishes necrotic arterial blood flow and increases venous drainage
25. On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. Nurse Ruth expects to prepare the client for which initial treatment?
a. Radiation therapy
b. Major surgery
c. Chemotherapy
d. None (At this advanced stage, ovarian cancer isn’t treatable.)