NCLEX Physiological Integrity 4

Question 1

A client taking warfarin has an INR of 5.2 with no signs of bleeding. What is the nurse's best action?

Accepted Answer

Hold the next warfarin dose and notify the provider

Answer

A supratherapeutic INR without bleeding is managed by holding warfarin and contacting the provider, who may order low-dose oral vitamin K.

Question 2

A client's serum potassium is 6.8 mEq/L. Which ECG finding should the nurse expect?

Accepted Answer

Tall, peaked T waves

Answer

Hyperkalemia classically produces tall, peaked T waves, while U waves and flattened T waves suggest hypokalemia.

Question 3

Twelve hours after a total thyroidectomy, a client reports tingling around the mouth and in the fingertips. What should the nurse assess next?

Accepted Answer

Chvostek's and Trousseau's signs

Answer

Perioral and fingertip tingling suggest hypocalcemia from parathyroid injury, which is confirmed by Chvostek's and Trousseau's signs.

Question 4

The nurse notes continuous bubbling in the water-seal chamber of a client's chest drainage system. What does this indicate?

Accepted Answer

An air leak in the system or from the client

Answer

Continuous bubbling in the water-seal chamber signals an air leak, whereas intermittent bubbling with exhalation or coughing can be expected with a pneumothorax.

Question 5

A client is admitted with diabetic ketoacidosis. Which prescription should the nurse implement first?

Accepted Answer

0.9% sodium chloride IV infusion

Answer

Fluid resuscitation with isotonic saline is the first priority in DKA to correct severe dehydration and restore perfusion.

NCLEX Practice Test

NCLEX Practice Test

NCLEX Physiological Integrity 4