Physiological Integrity Flashcards
7 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 7 Physiological Integrity flashcards as text
A client taking warfarin has an INR of 5.2 with no signs of bleeding. What is the nurse's best action?
Answer: Hold the next warfarin dose and notify the provider
A supratherapeutic INR without bleeding is managed by holding warfarin and contacting the provider, who may order low-dose oral vitamin K.
A client's serum potassium is 6.8 mEq/L. Which ECG finding should the nurse expect?
Answer: Tall, peaked T waves
Hyperkalemia classically produces tall, peaked T waves, while U waves and flattened T waves suggest hypokalemia.
Twelve hours after a total thyroidectomy, a client reports tingling around the mouth and in the fingertips. What should the nurse assess next?
Answer: Chvostek's and Trousseau's signs
Perioral and fingertip tingling suggest hypocalcemia from parathyroid injury, which is confirmed by Chvostek's and Trousseau's signs.
The nurse notes continuous bubbling in the water-seal chamber of a client's chest drainage system. What does this indicate?
Answer: An air leak in the system or from the client
Continuous bubbling in the water-seal chamber signals an air leak, whereas intermittent bubbling with exhalation or coughing can be expected with a pneumothorax.
A client is admitted with diabetic ketoacidosis. Which prescription should the nurse implement first?
Answer: 0.9% sodium chloride IV infusion
Fluid resuscitation with isotonic saline is the first priority in DKA to correct severe dehydration and restore perfusion.
A client with a T4 spinal cord injury suddenly reports a pounding headache and has a BP of 210/110 mm Hg. What is the nurse's first action?
Answer: Raise the head of the bed to a sitting position
In autonomic dysreflexia, sitting the client upright immediately lowers blood pressure before the nurse searches for the trigger.
Before administering digoxin to an adult client, the nurse should withhold the dose if which finding is present?
Answer: Apical pulse of 54 beats/min
Digoxin is generally held when the adult apical pulse is below 60 beats/min because it slows AV conduction.
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