Physiological Integrity Flashcards
6 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Physiological Integrity flashcards as text
A nurse is caring for a client with a spinal cord injury at the T4 level. The client develops a sudden severe headache (9/10), blood pressure of 190/100 mmHg, and profuse diaphoresis above the level of injury. Which condition should the nurse suspect?
Answer: Autonomic dysreflexia
Autonomic dysreflexia is a life-threatening complication of spinal cord injuries above T6, characterized by a sudden extreme hypertension, pounding headache, and diaphoresis above the injury level, triggered by a noxious stimulus below the injury.
A nurse is caring for a client receiving peritoneal dialysis. The nurse notes that the dialysate drainage is cloudy. Which action should the nurse take first?
Answer: Stop the dialysis and notify the provider immediately
Cloudy dialysate effluent is a classic sign of peritonitis — the most serious complication of peritoneal dialysis. The nurse must stop the dialysis and notify the provider immediately so antibiotic therapy can be initiated promptly.
A nurse is assessing a client with suspected deep vein thrombosis (DVT) in the right lower leg. Which assessment technique should the nurse avoid?
Answer: Performing Homan's sign (dorsiflexion of the foot)
Homan's sign (forceful dorsiflexion of the foot to elicit calf pain) should not be performed when DVT is suspected because it can dislodge the thrombus and cause pulmonary embolism. It has also been found to be an unreliable diagnostic test.
A nurse is caring for a client experiencing a generalized tonic-clonic seizure. Which action has the highest priority?
Answer: Turn the client to a side-lying position and protect the head
During a seizure, the highest priority is protecting the client from injury. Turning to a side-lying position prevents aspiration of secretions and keeps the airway open; protecting the head prevents traumatic injury.
A nurse is caring for a client with a new tracheostomy who has thick secretions that are difficult to suction. Which intervention will most effectively improve secretion clearance?
Answer: Ensure adequate systemic hydration and use tracheostomy humidification
Adequate systemic hydration and tracheostomy humidification are the most effective interventions for preventing and managing thick secretions. Bypassing the nose eliminates the natural humidification of the upper airway, making supplemental humidification essential.
A nurse is caring for a client with diabetic ketoacidosis (DKA). The provider orders regular insulin 0.1 unit/kg/hour IV infusion. The client weighs 80 kg. The pharmacy provides regular insulin 100 units in 100 mL normal saline. At what rate should the nurse set the infusion pump (mL/hour)?
Answer: 8 mL/hour
Dose calculation: 0.1 unit/kg/hour × 80 kg = 8 units/hour. Concentration = 100 units/100 mL = 1 unit/mL. Rate = 8 units/hour ÷ 1 unit/mL = 8 mL/hour.