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

Severe pain disproportionate to the injury that is unresponsive to analgesics is the hallmark early sign of compartment syndrome. This is a surgical emergency requiring fasciotomy to relieve pressure. Pain relief with elevation is not expected — elevation can worsen ischemia in compartment syndrome.

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

Large-volume infusion of normal saline (154 mEq/L of chloride) can cause a dilutional hyperchloremic metabolic acidosis, as excess chloride displaces bicarbonate. This is a well-recognized complication of resuscitation with isotonic saline.

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

Hyperkalemia (K+ 6.2 mEq/L) is the most immediately life-threatening complication because potassium levels above 6.0 mEq/L can cause fatal cardiac dysrhythmias. Elevated BUN and creatinine indicate chronic renal decline but are not acute emergencies.

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

pH 7.30 is acidotic. The elevated PaCO2 of 54 mmHg indicates CO2 retention, identifying the cause as respiratory. HCO3 of 24 mEq/L is normal, meaning there is no metabolic compensation yet. This is uncompensated respiratory acidosis, common with hypoventilation on the ventilator.

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

Cirrhosis causes portal hypertension (leading to ascites), impaired bilirubin metabolism (jaundice), and abnormal estrogen metabolism (spider angiomata). Serum albumin is typically low due to impaired hepatic synthesis, and clients often have hypotension rather than hypertension.

NCLEX Practice Test

NCLEX Practice Test

Physiological Integrity