Physiological Integrity 2

Question 1

A nurse is caring for a client who returns from surgery with a Jackson-Pratt (JP) drain in place. Which action should the nurse take to maintain proper function of the drain?

Accepted Answer

Empty and re-compress the bulb every 8 hours or when half full

Answer

Jackson-Pratt drains work on gentle suction created by compressing the bulb. The nurse empties and re-compresses (re-establishes suction) the bulb when it is half full or per facility policy, typically every 8 hours, to maintain effective drainage.

Question 2

A nurse is caring for a client 12 hours post-operative following a right colostomy. The nurse assesses the stoma and notes it is dark purple-black in color. Which action is most appropriate?

Accepted Answer

Notify the surgeon immediately, as this finding indicates stoma ischemia

Answer

A stoma that is dark purple or black indicates ischemia or necrosis — a surgical emergency. A healthy stoma should be pink or red and moist. The surgeon must be notified immediately as this finding may require emergent surgical intervention.

Question 3

A nurse is performing a neurological assessment on a client with a suspected stroke. Which finding requires the most urgent intervention?

Accepted Answer

Glasgow Coma Scale score of 8

Answer

A Glasgow Coma Scale (GCS) score of 8 indicates severe neurological impairment with significant risk of loss of protective airway reflexes. This is the most urgent finding, as airway protection is the priority (GCS ≤8 typically necessitates intubation consideration).

Question 4

A nurse is caring for a client who is 2 days post-operative after abdominal surgery. The client's wound is closed with staples. The nurse notes the wound edges are approximated, with minimal serous drainage on the dressing. Which term best describes this type of wound healing?

Accepted Answer

Primary intention

Answer

Primary intention healing occurs when wound edges are surgically approximated (closed with sutures, staples, or surgical tape), resulting in minimal tissue loss and a clean, healing wound with little scarring.

Question 5

A nurse is assessing an adult client's blood pressure in the right arm and obtains a reading of 148/92 mmHg. Before documenting hypertension, which action is most appropriate?

Accepted Answer

Obtain the blood pressure in both arms and compare, and repeat in the same arm after 5 minutes

Answer

A single elevated blood pressure reading is not sufficient to diagnose or document hypertension. The nurse should confirm the reading by measuring in both arms (to detect coarctation or peripheral vascular disease) and repeating after 5 minutes to eliminate transient elevation.

NCLEX Practice Test

NCLEX Practice Test

Physiological Integrity 2