Physiological Integrity

Question 1

What is the primary purpose of monitoring vital signs?

Accepted Answer

To identify potential complications early

Answer

Monitoring vital signs (temperature, pulse, respiration, blood pressure, and oxygen saturation) provides crucial baseline data and indicates changes in a patient's physiological status. Significant deviations from normal ranges can signal the onset of acute complications or a worsening condition. This allows nurses to intervene promptly, preventing further deterioration and ensuring patient safety.

Question 2

Which of the following is a sign of hypovolemic shock?

Accepted Answer

Weak, thready pulse and low blood pressure

Answer

Hypovolemic shock results from a significant loss of blood or fluid volume, leading to inadequate tissue perfusion throughout the body. The body attempts to compensate by increasing heart rate, but the pulse becomes weak and thready due to decreased circulating volume. Blood pressure drops as the heart struggles to pump sufficient blood, indicating a critical and life-threatening state.

Question 3

What is the correct nursing intervention for a patient with acute pain?

Accepted Answer

Assessing the pain level and administering analgesics as prescribed

Answer

Acute pain requires prompt and effective management to promote comfort and facilitate recovery. The nurse's role involves thoroughly assessing the patient's pain level using a standardized scale and then administering prescribed analgesics in a timely manner. This ensures the patient receives appropriate relief, prevents unnecessary suffering, and supports healing.

Question 4

Which of the following is a common complication of immobility?

Accepted Answer

Increased risk for pressure ulcers

Answer

Immobility significantly increases the risk for pressure ulcers (bedsores) because sustained pressure on bony prominences compromises blood flow to the skin and underlying tissues. Without regular repositioning and meticulous skin care, tissue ischemia and breakdown can occur. Other complications include muscle atrophy, contractures, and respiratory issues.

Question 5

How should the nurse assess a patient's respiratory rate?

Accepted Answer

By visually observing the rise and fall of the chest

Answer

To accurately assess a patient's respiratory rate, the nurse should visually observe the rise and fall of the chest or abdomen for a full minute. It is best to do this discreetly, without the patient's awareness, as they may unconsciously alter their breathing pattern if they know they are being observed. This method provides an objective and accurate measure of respiratory effort.

NCLEX Practice Test

NCLEX Practice Test

Physiological Integrity