Physiological Integrity

Question 1

A nurse is assessing a client with acute compartment syndrome in the right lower leg following a tibial fracture. Which finding requires immediate intervention?

Accepted Answer

Pain that is disproportionate to the injury and unrelieved by opioid analgesics

Answer

Mild bruising over the fracture site

Answer

Pain that is relieved by elevation of the affected limb

Answer

A capillary refill time of 2 seconds in the right toes

Question 2

A nurse is monitoring a client who received a large volume of 0.9% normal saline during resuscitation. Which acid-base imbalance should the nurse anticipate?

Accepted Answer

Hyperchloremic metabolic acidosis

Answer

Metabolic alkalosis

Answer

Respiratory acidosis

Answer

Respiratory alkalosis

Question 3

A nurse assessing a client with chronic kidney disease (CKD) stage 4 finds the following labs: potassium 6.2 mEq/L, BUN 68 mg/dL, creatinine 4.1 mg/dL. Which finding requires the most urgent intervention?

Accepted Answer

Potassium of 6.2 mEq/L

Answer

BUN of 68 mg/dL

Answer

Creatinine of 4.1 mg/dL

Answer

All values require equal urgency

Question 4

A nurse is caring for a client on mechanical ventilation with the following ABG results: pH 7.30, PaCO2 54 mmHg, HCO3 24 mEq/L, PaO2 78 mmHg. How should the nurse interpret these values?

Accepted Answer

Respiratory acidosis, uncompensated

Answer

Metabolic acidosis, uncompensated

Answer

Respiratory alkalosis, compensated

Answer

Metabolic alkalosis, partially compensated

Question 5

A nurse is performing a physical assessment on a client with cirrhosis of the liver. Which finding is most consistent with this diagnosis?

Accepted Answer

Ascites, jaundice, and spider angiomata

Answer

Pitting edema of the feet and ankles only

Answer

Hypertension and elevated serum albumin

Answer

Bradycardia and peripheral vasoconstriction

Question 6

A nurse is caring for a client who is 2 hours post-thyroidectomy. The client suddenly develops carpopedal spasm, tingling around the mouth, and a positive Chvostek's sign. The nurse's priority action is to:

Accepted Answer

Notify the provider immediately and prepare to administer IV calcium gluconate

Answer

Administer prescribed oral calcium carbonate and reassess in 30 minutes

Answer

Place the client in Trendelenburg position to improve cerebral perfusion

Answer

Increase the IV fluid rate to dilute the electrolyte imbalance