Delaware RN: Physiological Integrity Practice Test

Practice test questions — RN: Physiological Integrity

1. What is the normal range for adult serum potassium?

   • 1.5-2.5 mEq/L
   • 3.5-5.0 mEq/L ✓
   • 5.5-7.0 mEq/L
   • 8.0-10.0 mEq/L

   Normal serum potassium is 3.5-5.0 mEq/L (or 3.5-5.0 mmol/L). Potassium is the major intracellular cation and is critical for normal cardiac, neuromuscular, and cellular function. Hypokalemia (below 3.5) causes muscle weakness, cramping, arrhythmias (U waves on ECG, flattened T waves, ST depression),…

2. What is the normal range for adult fasting blood glucose?

   • 20-50 mg/dL
   • 70-100 mg/dL ✓
   • 150-200 mg/dL
   • 300-400 mg/dL

   Normal fasting blood glucose is 70-100 mg/dL (3.9-5.5 mmol/L). Values 100-125 mg/dL indicate prediabetes (impaired fasting glucose); 126 mg/dL or higher on two separate tests indicates diabetes. Hypoglycemia (below 70) causes shakiness, sweating, anxiety, hunger, confusion, and at severe levels (bel…

3. A client is receiving warfarin (Coumadin). What lab value is monitored to assess effectiveness?

   • Hemoglobin
   • Prothrombin Time (PT) and International Normalized Ratio (INR) ✓
   • Partial Thromboplastin Time (PTT)
   • Platelet count

   Warfarin is monitored using PT/INR. Therapeutic INR ranges: 2.0-3.0 for most conditions (atrial fibrillation, DVT, PE, after major heart valve surgery); 2.5-3.5 for mechanical heart valves and recurrent thromboembolism. INR above 3.0-3.5 (depending on indication) increases bleeding risk; below the t…

4. Which assessment should the nurse perform before administering digoxin?

   • Blood pressure only
   • Apical heart rate for a full minute — hold if less than 60 bpm in adults ✓
   • Respiratory rate
   • Temperature

   Digoxin is a cardiac glycoside used for atrial fibrillation and heart failure. It slows heart rate (negative chronotropy) and increases contractility (positive inotropy). The nurse counts the apical heart rate for a FULL minute before administration. Hold and notify the provider if apical HR is belo…

5. What is the appropriate first action for a conscious client with a blood glucose of 50 mg/dL who reports feeling shaky and sweaty?

   • Administer IV glucose
   • Give 15 grams of fast-acting carbohydrate (e.g., 4 oz juice, 3-4 glucose tablets) and recheck blood glucose in 15 minutes ✓
   • Wait and see if symptoms resolve
   • Administer insulin

   The 'Rule of 15' is the standard treatment for hypoglycemia in a conscious, swallowing client: (1) Give 15 grams of fast-acting carbohydrate — options include 4 oz fruit juice, 4 oz regular (not diet) soda, 1 tbsp honey or sugar, 3-4 glucose tablets, 8 oz milk; (2) Wait 15 minutes; (3) Recheck blood…

6. What is the difference between Type 1 and Type 2 diabetes?

   • They are the same disease
   • Type 1 is autoimmune destruction of pancreatic beta cells causing absolute insulin deficiency (insulin required); Type 2 is insulin resistance with relative insulin deficiency (may be managed with diet, oral medications, eventually often requires insulin) ✓
   • Type 2 is autoimmune
   • Type 1 only affects adults

   Type 1 diabetes (formerly juvenile/insulin-dependent diabetes): autoimmune destruction of pancreatic beta cells leads to absolute insulin deficiency. Onset usually in childhood/young adulthood but can occur at any age. Always requires insulin therapy. About 5-10% of diabetes cases. Higher risk of DK…

7. A client presents with crushing chest pain radiating to the left arm. ECG shows ST elevation. What is the priority intervention?

   • Document the symptoms and reassess in an hour
   • Initiate the STEMI protocol: oxygen, aspirin, nitroglycerin, IV access, prepare for emergent reperfusion (PCI within 90 minutes or thrombolytics within 30 minutes if PCI unavailable) ✓
   • Give oral antacids
   • Discharge home with follow-up

   ST-elevation myocardial infarction (STEMI) is a medical emergency where coronary occlusion is causing actively-progressing myocardial damage. 'Time is muscle' — delays in reperfusion increase infarct size and worsen outcomes. Standard initial management (often remembered as MONA-BASH or similar mnem…

8. What is the most common symptom of myocardial infarction in women that may differ from men's presentation?

   • Identical to men's presentation
   • Women may present with atypical symptoms: fatigue, shortness of breath, nausea, indigestion, back pain, jaw pain — sometimes without classic crushing chest pain ✓
   • Always asymptomatic
   • Only leg pain

   Women, elderly clients, and people with diabetes may present with atypical MI symptoms that delay diagnosis. Classic 'textbook' MI: crushing substernal chest pain radiating to left arm or jaw, diaphoresis, nausea, sense of impending doom. Atypical presentations more common in women, elderly, diabeti…

9. A client has a Stage 2 pressure injury on the sacrum. What is the most appropriate nursing intervention?

   • Massage the area to improve circulation
   • Keep the area clean and dry, use appropriate dressings (e.g., hydrocolloid or foam), reposition every 2 hours, address nutrition and moisture ✓
   • Apply heat continuously
   • Use only saline gauze with daily changes

   Pressure injury staging (NPIAP): Stage 1 — intact skin with non-blanchable redness; Stage 2 — partial-thickness skin loss with exposed dermis (looks like a shallow open ulcer, blister, or abrasion); Stage 3 — full-thickness skin loss exposing subcutaneous fat; Stage 4 — full-thickness with exposed b…

10. A client receiving morphine for postoperative pain has a respiratory rate of 8 breaths per minute. What is the priority action?

    • Continue monitoring
    • Hold further opioid doses, stimulate the client, assess oxygen saturation, prepare to administer naloxone (Narcan) if respiratory depression persists, notify provider ✓
    • Give another dose of morphine for pain
    • Apply oxygen and resume normal dosing

    Respiratory depression is the most serious adverse effect of opioids. A respiratory rate below 12 in adults warrants attention; below 10 is concerning; below 8 is critical. Priority actions: (1) Hold further opioid doses; (2) Stimulate the client (call name, gentle shake) and encourage deep breathin…

11. After administering an IV antibiotic, the client develops difficulty breathing, urticaria, and hypotension. What is the priority action?

    • Slow the infusion rate
    • Stop the infusion immediately, maintain airway, call for help, administer epinephrine per protocol, prepare for advanced airway management ✓
    • Document the reaction and continue
    • Administer another dose

    This is anaphylactic reaction to the IV antibiotic. Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action: (1) Stop the offending agent immediately — close the IV clamp; (2) Maintain the airway — anaphylaxis can cause rapid laryngeal swelling; (3) Call for help (rap…

12. A client with COPD reports difficulty breathing. The nurse notes oxygen saturation 88% on room air. What is the appropriate intervention?

    • Apply high-flow oxygen at 10 L/min via nasal cannula
    • Apply low-flow oxygen (1-2 L/min) via nasal cannula, titrating to maintain SpO2 around 88-92%, monitor for signs of CO2 retention ✓
    • Withhold oxygen
    • Use only room air

    COPD clients chronically retain CO2 (carbon dioxide); over time, their respiratory drive may rely on hypoxic drive rather than the normal hypercapnic drive. Giving high-flow oxygen can suppress this hypoxic drive, leading to CO2 retention, hypercapnia, and CO2 narcosis (confusion, sedation, eventual…

13. A postoperative client is at risk for deep vein thrombosis (DVT). Which intervention helps prevent DVT?

    • Strict bed rest
    • Early ambulation, sequential compression devices (SCDs), prophylactic anticoagulation as ordered, leg exercises while in bed ✓
    • Massaging the calves daily
    • Crossing the legs at the knees

    DVT prevention is a major postoperative concern. Virchow's triad of DVT risk: venous stasis, endothelial injury, hypercoagulability — all increased after surgery. Prevention strategies: (1) Early ambulation — get clients up walking as soon as safely possible, even on postoperative day 0; (2) Sequent…

14. Which finding in a client receiving enteral feedings via nasogastric tube indicates possible aspiration?

    • Normal bowel sounds
    • New-onset cough, increased respiratory rate, decreased oxygen saturation, fever, abnormal lung sounds ✓
    • Increased appetite
    • Decreased urinary output

    Aspiration is a major risk of enteral feeding. Signs of aspiration: new-onset cough during or after feeding; increased respiratory rate; decreased oxygen saturation; fever (often delayed); abnormal lung sounds (crackles, decreased breath sounds, especially in dependent areas); change in mental statu…

15. What is the normal range for adult serum sodium?

    • 100-110 mEq/L
    • 135-145 mEq/L ✓
    • 150-160 mEq/L
    • 180-200 mEq/L

    Normal serum sodium is 135-145 mEq/L. Sodium is the major extracellular cation, essential for fluid balance and neuromuscular function. Hyponatremia (below 135): symptoms based on rate of change — acute hyponatremia is more dangerous than chronic. Symptoms include nausea, headache, confusion, lethar…

16. What is the most important teaching point for a client newly prescribed long-term corticosteroid therapy (prednisone)?

    • Stop the medication when symptoms improve
    • Never stop the medication abruptly — taper as directed by the provider to prevent adrenal insufficiency ✓
    • Take the medication only as needed
    • Avoid all foods

    Long-term exogenous corticosteroids suppress the hypothalamic-pituitary-adrenal (HPA) axis. After about 2-3 weeks of suppressive doses, the adrenal glands stop producing endogenous cortisol. Abrupt discontinuation can cause acute adrenal insufficiency (Addisonian crisis): severe weakness, hypotensio…

17. A client with heart failure is prescribed furosemide (Lasix). What is the primary mechanism and a key adverse effect?

    • Beta-blocker; bradycardia
    • Loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle, increasing urinary excretion of water and electrolytes; common adverse effects include hypokalemia, hyponatremia, dehydration, ototoxicity (especially with rapid IV administration) ✓
    • ACE inhibitor; cough
    • Calcium channel blocker; constipation

    Furosemide (Lasix) is a loop diuretic — the most potent class of diuretic. Mechanism: inhibits the sodium-potassium-chloride co-transporter in the ascending loop of Henle, causing large amounts of sodium, chloride, potassium, and water to be excreted. Used for: heart failure, edema, hypertension, as…

18. What is the onset, peak, and duration of regular (short-acting) insulin?

    • Onset 15 minutes, peak 1 hour, duration 24 hours
    • Onset 30-60 minutes, peak 2-4 hours, duration 5-8 hours ✓
    • Onset 2 hours, peak 12 hours, duration 24 hours
    • Onset immediate, no peak, duration 4 hours

    Regular insulin (Humulin R, Novolin R) is the short-acting insulin. Approximate pharmacokinetics: onset 30-60 minutes, peak 2-4 hours, duration 5-8 hours. Give 30 minutes before meals. The only insulin that can be given IV (for DKA, hyperkalemia, perioperative use). Other insulin types: Rapid-acting…

19. What is the most important nursing assessment after a thoracentesis procedure?

    • Bowel sounds
    • Respiratory status (rate, effort, oxygen saturation, breath sounds) for signs of pneumothorax ✓
    • Bladder distention
    • Pupil response

    Thoracentesis is the insertion of a needle through the chest wall to remove fluid from the pleural space. Main complications: (1) Pneumothorax — air enters the pleural space, possibly causing lung collapse; signs include sudden shortness of breath, sharp chest pain, decreased or absent breath sounds…

20. A client with cirrhosis develops increasing abdominal girth, ankle edema, and dyspnea. What is the most likely complication?

    • Constipation
    • Ascites — accumulation of fluid in the peritoneal cavity due to portal hypertension and hypoalbuminemia ✓
    • Pneumonia only
    • Heart attack

    Ascites is a common complication of cirrhosis caused by portal hypertension (increased pressure in the portal venous system due to liver fibrosis) combined with hypoalbuminemia (the liver can't produce enough albumin to maintain oncotic pressure). Fluid leaks into the peritoneal cavity. Signs: incre…

21. What is the priority nursing diagnosis for a client with acute heart failure exacerbation presenting with severe shortness of breath, pink frothy sputum, and crackles throughout lung fields?

    • Constipation
    • Impaired gas exchange related to pulmonary edema ✓
    • Anxiety only
    • Activity intolerance

    This presentation describes acute pulmonary edema — fluid in the alveoli — a life-threatening complication of acute heart failure. The priority diagnosis is impaired gas exchange because oxygen cannot diffuse across fluid-filled alveoli. Other features: orthopnea (unable to lie flat), paroxysmal noc…

22. A client is prescribed metformin for type 2 diabetes. What is an important teaching point?

    • Take with alcohol
    • Hold metformin and notify provider before procedures requiring contrast dye, due to risk of lactic acidosis ✓
    • Take only at bedtime
    • Stop when blood sugar normalizes

    Metformin is the first-line oral medication for type 2 diabetes. Mechanism: decreases hepatic glucose production, increases peripheral insulin sensitivity. Key teaching points: (1) Take with meals to minimize GI side effects (nausea, diarrhea, abdominal discomfort — often improve over weeks); (2) Ho…

23. What is the proper procedure for changing a sterile dressing on a surgical wound?

    • No special technique required
    • Hand hygiene; gather supplies; explain procedure; don clean gloves to remove old dressing; assess wound; perform hand hygiene; set up sterile field; don sterile gloves; clean wound from cleanest to dirtiest area using each gauze once; apply sterile dressing; document ✓
    • Use bare hands
    • Change only when soiled

    Sterile dressing changes follow specific aseptic technique: (1) Hand hygiene, gather supplies, explain procedure to client, position appropriately; (2) Don clean gloves; remove old dressing carefully (note drainage, odor, intact ness); discard in appropriate container; remove gloves; perform hand hy…

24. A client is admitted with acute pancreatitis. Which intervention is most important initially?

    • Encourage oral intake to prevent dehydration
    • NPO (nothing by mouth) to rest the pancreas, IV fluids, pain management, monitor for complications (hypocalcemia, shock, ARDS, organ failure) ✓
    • Give a high-fat diet
    • Discharge home with rest

    Acute pancreatitis is inflammation of the pancreas with severe abdominal pain (epigastric, radiating to back), nausea, vomiting, elevated amylase and lipase. Most common causes: gallstones and alcohol use. Severe cases can progress to systemic inflammatory response, ARDS, organ failure, death. Initi…

25. What is the normal range for adult hemoglobin?

    • 5-8 g/dL
    • 12-16 g/dL for females; 14-18 g/dL for males ✓
    • 20-25 g/dL
    • 30-35 g/dL

    Normal hemoglobin (Hgb): 12-16 g/dL for adult females; 14-18 g/dL for adult males. Lower values indicate anemia; higher values indicate polycythemia. Anemia (Hgb below normal): symptoms include fatigue, weakness, pallor, shortness of breath, tachycardia, palpitations, dizziness. Common causes: blood…

26. A client with heart failure is prescribed digoxin 0.125 mg daily. Before administration, which assessment is the PRIORITY?

    • Check the client's blood pressure
    • Assess the apical pulse for 1 full minute — if below 60 bpm, hold the dose and notify the provider; also check potassium level (hypokalemia increases digoxin toxicity risk) ✓
    • Check the client's weight only
    • Ask if the client has had any chest pain

    DIGOXIN (a cardiac glycoside) has a narrow therapeutic index and specific assessment requirements before administration. PRIORITY ASSESSMENT: APICAL PULSE — measure for a full 60 seconds; HOLD and notify provider if: below 60 bpm in adults; below 70 bpm in children; below 90 bpm in infants; POTASSIU…

27. A client's ABG results are: pH 7.28, PaCO₂ 58 mmHg, HCO₃ 26 mEq/L, PaO₂ 68 mmHg. How does the nurse interpret this?

    • Metabolic acidosis with compensation
    • Respiratory acidosis — the pH is below 7.35 (acidosis); CO₂ is elevated above 45 mmHg (respiratory cause — CO₂ retention indicates hypoventilation); HCO₃ is normal (no metabolic compensation yet, suggesting an acute process) ✓
    • Respiratory alkalosis
    • Normal ABG with mild hypoxaemia

    ABG INTERPRETATION uses a systematic four-step approach: STEP 1 — pH: 7.28 is BELOW 7.35 → ACIDOSIS; STEP 2 — Identify the cause: PaCO₂ 58 mmHg is ABOVE 45 mmHg → RESPIRATORY cause (CO₂ is an acid; elevated CO₂ causes acidosis); STEP 3 — Check compensation: HCO₃ 26 mEq/L is within normal range (22-2…

28. A client with a deep vein thrombosis (DVT) is started on heparin infusion. After 24 hours, the aPTT is 140 seconds (therapeutic range 60-100 seconds). What is the PRIORITY nursing action?

    • Continue the infusion at the current rate
    • Stop the infusion and notify the provider immediately — an aPTT of 140 seconds is supratherapeutic and indicates over-anticoagulation with significant bleeding risk; assess for signs of bleeding ✓
    • Increase the infusion rate
    • Draw a repeat aPTT in 8 hours without changing anything

    HEPARIN MONITORING AND SAFETY is one of the most high-stakes pharmacology topics on the NCLEX. THERAPEUTIC aPTT RANGE: Typically 60-100 seconds (or 1.5-2.5 times the normal value of approximately 30-40 seconds); some institutions use anti-Xa levels instead. aPTT 140 SECONDS: This is well above the t…

29. A client 2 hours post-appendectomy reports sudden onset of severe abdominal pain, rigid abdomen, and has a temperature of 39.8°C (103.6°F). What does the nurse suspect?

    • Normal post-operative discomfort
    • Peritonitis — inflammation of the peritoneum, likely from surgical contamination or perforation; this is a surgical emergency requiring immediate notification of the provider ✓
    • Urinary tract infection
    • Incentive spirometry-related muscle strain

    PERITONITIS is inflammation of the peritoneum (the membrane lining the abdominal cavity and covering abdominal organs). In the post-appendectomy context, it suggests either: (1) the appendix perforated at or during surgery; (2) surgical site contamination; (3) anastomotic leak. CLINICAL PRESENTATION…

30. A nurse is preparing to administer a blood transfusion. Which assessment finding requires stopping the transfusion IMMEDIATELY?

    • The client reports feeling slightly cold
    • The client develops sudden chills, fever, back pain, and dark urine 15 minutes into the transfusion — these are signs of an acute haemolytic transfusion reaction (ABO incompatibility) ✓
    • The client's BP increases by 5 mmHg
    • The client asks for a warm blanket

    ACUTE HAEMOLYTIC TRANSFUSION REACTION (AHTR) is the most life-threatening transfusion complication and is caused by ABO blood group incompatibility. CLASSIC SIGNS (appear within the first 15-50 mL): Sudden chills and fever; Low back pain (retroperitoneal lysis of red blood cells); Dark/red-brown uri…

31. A client receiving morphine sulphate 4 mg IV reports that their pain hasn't improved at all after 30 minutes. What is the nurse's BEST action?

    • Tell the client to wait another hour before the next dose
    • Reassess pain level thoroughly (location, quality, intensity, radiation), check vital signs, review the PRN order parameters, and contact the provider if the pain is uncontrolled and another dose is clinically appropriate — do not delay assessment ✓
    • Administer another full dose without checking vitals
    • Document 'pain controlled' and continue regular checks

    INADEQUATE PAIN CONTROL requires systematic reassessment before any intervention. The nurse cannot simply give more opioid without assessment. COMPREHENSIVE REASSESSMENT: PAIN ASSESSMENT: Use a validated scale (NRS 0-10, Wong-Baker FACES, FLACC for non-verbal); Ask about location, quality (sharp, bu…

32. A client is admitted with a serum potassium of 6.2 mEq/L. Which finding requires the nurse's MOST urgent attention?

    • Mild muscle weakness reported by the client
    • Tall peaked T waves on the ECG monitor — hyperkalemia-induced cardiac changes are immediately life-threatening; ventricular fibrillation can occur without warning ✓
    • A potassium level of 6.2 mEq/L alone
    • Moderate thirst

    HYPERKALEMIA (K+ above 5.0 mEq/L) produces a predictable progression of ECG changes that correlates with potassium level and toxicity: K+ 5.5-6.5 mEq/L: PEAKED T WAVES — tall, narrow, symmetrical T waves; this is the first ECG sign; K+ 6.5-7.5 mEq/L: prolonged PR interval, widened QRS, loss of P wav…

33. A client with type 1 diabetes is found unresponsive with a blood glucose of 32 mg/dL. They cannot swallow. What is the PRIORITY nursing action?

    • Administer oral glucose gel inside the cheek
    • Administer 50% dextrose (D50W) IV per order, or glucagon IM/SubQ if no IV access — do NOT give anything by mouth to an unresponsive patient (aspiration risk) ✓
    • Encourage the client to drink orange juice
    • Call for a diet consult

    SEVERE HYPOGLYCAEMIA in an UNRESPONSIVE patient requires PARENTERAL glucose administration. Attempting to give anything orally to an unresponsive patient risks ASPIRATION — a life-threatening complication. BLOOD GLUCOSE OF 32 mg/dL: Severe hypoglycaemia (normal fasting glucose 70-100 mg/dL); symptom…

34. A nurse is caring for a client who had a total laryngectomy. Which finding requires the MOST urgent intervention?

    • The client cannot speak
    • Absence of breath sounds and decreasing SpO₂ — the laryngectomy stoma is the client's only airway; any obstruction is an immediate airway emergency ✓
    • Mild surgical site swelling
    • The client requests a mirror

    TOTAL LARYNGECTOMY creates a PERMANENT STOMA (opening) in the anterior neck as the client's ONLY airway — the trachea is no longer connected to the mouth and nose. CRITICAL CONCEPT: A standard bag-valve-mask over the face does NOT ventilate a laryngectomy patient — the mouth and nose are disconnecte…

35. A client with acute pancreatitis reports 9/10 abdominal pain and is NPO. Which nursing intervention provides the MOST direct comfort?

    • Encourage the client to walk in the hallway
    • : Administer analgesics as ordered (opioids are appropriate for severe acute pancreatitis pain — the concern about morphine and the sphincter of Oddi is not evidence-based; hydromorphone or fentanyl are preferred); position in a fetal position (knees drawn up) which reduces tension on the retroperitoneal space ✓
    • Offer clear liquids to soothe the stomach
    • Apply a warm compress to the abdomen

    ACUTE PANCREATITIS pain management requires understanding both pharmacological and non-pharmacological approaches. PAIN MANAGEMENT: Opioid analgesics are appropriate and necessary for severe acute pancreatitis — the pain is severe and uncontrolled pain increases physiological stress; THE MORPHINE/SP…

36. A client with STEMI is prescribed tissue plasminogen activator (tPA/alteplase). Which assessment finding is an ABSOLUTE CONTRAINDICATION to administration?

    • Blood pressure of 148/90 mmHg
    • History of haemorrhagic stroke at any time, or ischaemic stroke within the past 3 months — these are absolute contraindications to thrombolytic therapy regardless of the potential cardiac benefit ✓
    • Age over 65
    • Mild allergy to contrast dye

    THROMBOLYTIC THERAPY (tPA, alteplase, tenecteplase) for STEMI carries a serious risk of HAEMORRHAGE — including intracranial haemorrhage (ICH), which can be fatal or permanently disabling. ABSOLUTE CONTRAINDICATIONS to thrombolytics: PRIOR HAEMORRHAGIC STROKE at any time — a prior haemorrhagic strok…

37. A client is scheduled for a colonoscopy. Which pre-procedure assessment finding is MOST important to report to the provider?

    • The client had a small meal 12 hours ago
    • The client takes warfarin daily — anticoagulants significantly increase the risk of GI bleeding during and after colonoscopy with biopsy; the provider will need to determine whether to stop/bridge anticoagulation before the procedure ✓
    • The client has mild anxiety about the procedure
    • The client prefers to have the procedure with sedation

    PRE-PROCEDURE ASSESSMENT for colonoscopy must identify bleeding risk factors because colonoscopy can involve biopsy, polyp removal, and other interventions that create mucosal wounds. ANTICOAGULANTS: Warfarin, direct oral anticoagulants (apixaban, rivaroxaban, dabigatran), and antiplatelet agents (c…

38. A client with chronic kidney disease stage 4 has a serum phosphorus of 6.8 mg/dL (normal 2.5-4.5). What dietary teaching is MOST relevant?

    • Increase dairy intake for calcium
    • Restrict phosphorus-containing foods — especially dairy, dark cola beverages, processed foods, nuts, and chocolate; phosphate binders are taken WITH meals to block dietary phosphate absorption ✓
    • Increase fluid intake to 3 litres daily
    • Eat more protein-rich foods

    HYPERPHOSPHATAEMIA in CKD occurs because damaged kidneys cannot excrete phosphate effectively. ELEVATED PHOSPHATE has serious consequences: BINDS CALCIUM — hyperphosphataemia causes hypocalcaemia by precipitation (calcium binds with phosphate and deposits in tissues rather than circulating); CALCIPH…

39. A client is prescribed metoprolol succinate (Toprol-XL) for hypertension. Which client education point is MOST important?

    • Take the medication on an empty stomach
    • Never abruptly stop this medication — sudden discontinuation of a beta-blocker can cause rebound hypertension, tachycardia, angina, and even myocardial infarction; if stopping is necessary, the dose should be tapered gradually under medical supervision ✓
    • Expect an immediate significant drop in blood pressure on day one
    • This medication is safe to take with grapefruit juice

    BETA-BLOCKER DISCONTINUATION SAFETY is the most critical education point for any patient taking a beta-blocker long-term. MECHANISM: Chronic beta-blockade causes upregulation of beta-adrenergic receptors (the body compensates by growing more receptors); abrupt discontinuation exposes these upregulat…

40. A client admitted with acute decompensated heart failure has SpO₂ of 88% and audible crackles throughout both lung fields. What is the PRIORITY nursing action?

    • Insert a urinary catheter for accurate output measurement
    • Elevate the head of the bed to high Fowler's position (90 degrees) and administer supplemental oxygen per order — this is the fastest non-pharmacological intervention to improve oxygenation in pulmonary oedema ✓
    • Obtain a 12-lead ECG
    • Administer a scheduled oral diuretic dose

    ACUTE DECOMPENSATED HEART FAILURE with pulmonary oedema and SpO₂ of 88% is a respiratory emergency requiring immediate intervention. HIGH FOWLER'S POSITION (90 degrees or sitting bolt upright): MECHANISM — gravity pulls fluid from the upper lung fields downward; reduces venous return to the heart (d…

41. A client is receiving a continuous IV infusion of regular insulin for DKA. The blood glucose has decreased from 480 to 310 mg/dL over the past 2 hours. At what blood glucose level should the nurse add dextrose to the IV fluids?

    • When the blood glucose reaches 70 mg/dL
    • When the blood glucose reaches 200-250 mg/dL — dextrose is added to the IV fluid at this point to prevent hypoglycaemia while the insulin infusion continues to resolve the underlying ketoacidosis ✓
    • Dextrose is never added during insulin infusion
    • Only when the client complains of feeling hypoglycaemic

    DKA MANAGEMENT requires a critical understanding of why insulin therapy continues even after blood glucose normalises. THE DKA PRINCIPLE: DKA is resolved when the anion gap normalises and ketones are cleared — NOT simply when blood glucose returns to normal. The insulin infusion is the treatment for…

42. A client's BMP shows sodium 118 mEq/L (normal 135-145). They are confused and reporting a headache. What is the PRIORITY nursing concern?

    • Mild dehydration requiring oral fluids
    • Severe hyponatraemia — sodium of 118 mEq/L with neurological symptoms (confusion, headache) indicates brain oedema from hypotonic fluid shifts into brain cells; this is a neurological emergency ✓
    • Hypernatraemia
    • Normal electrolyte variation that doesn't require immediate action

    SEVERE HYPONATRAEMIA (sodium below 120-125 mEq/L with symptoms) is a neurological emergency. PATHOPHYSIOLOGY: When serum sodium falls rapidly, the extracellular fluid becomes hypotonic; water moves by osmosis into brain cells; brain cells swell (cerebral oedema); the skull cannot accommodate the swe…

43. A nurse is caring for a client following a lumbar spinal fusion. The client reports sudden onset of severe leg pain and is unable to move their toes. What is the PRIORITY action?

    • Administer a PRN analgesic per order
    • Immediately notify the surgeon — new neurological deficit (inability to move toes) and severe leg pain following spinal surgery may indicate spinal cord compression from haematoma or hardware failure; this is a surgical emergency with a narrow window for intervention ✓
    • Reposition the client and reassess in 30 minutes
    • Order a urinalysis to check for infection

    POST-SPINAL SURGERY NEUROLOGICAL DETERIORATION is a surgical emergency. NEW ONSET OF MOTOR DEFICIT (inability to move toes) in a post-laminectomy or spinal fusion patient is NEVER normal — it requires IMMEDIATE assessment and intervention. POSSIBLE CAUSES: EPIDURAL HAEMATOMA — blood collects in the …

44. A client with a nasogastric tube for decompression after bowel obstruction asks why they can't eat or drink. What is the BEST explanation?

    • 'The doctor ordered it and it's the rules.'
    • 'The tube is removing gas and fluid that would otherwise build up behind the obstruction — eating or drinking would add more fluid and worsen the distension and pressure; we need to let the bowel rest and the obstruction resolve or prepare for surgery' ✓
    • 'You'll be able to eat once the tube comes out tomorrow'
    • 'Eating could dislodge the tube'

    NASOGASTRIC TUBE FOR GI DECOMPRESSION — patient education requires explaining the rationale clearly so the patient understands and complies. THE EXPLANATION: BOWEL OBSTRUCTION creates a mechanical blockage; intestinal secretions (gastric juice, bile, pancreatic secretions) continue to be produced at…

45. A client taking lithium carbonate for bipolar disorder calls the nurse reporting nausea, diarrhoea, and a coarse hand tremor. Their last lithium level was 1.4 mEq/L (therapeutic 0.6-1.2). What should the nurse advise?

    • Continue taking the medication and these side effects will pass
    • Do not take the next dose; go to the nearest emergency room or call the provider immediately — a lithium level of 1.4 plus symptoms of nausea, diarrhoea, and coarse tremor indicates developing lithium toxicity ✓
    • Increase fluid and salt intake only
    • Cut the dose in half and see if it helps

    LITHIUM TOXICITY is a medical emergency requiring immediate intervention. The combination of supratherapeutic lithium level (1.4 mEq/L above the therapeutic range of 0.6-1.2) with SYMPTOMS of toxicity represents an urgent situation. LITHIUM TOXICITY PROGRESSION: EARLY (1.5-2.0 mEq/L): Fine-to-coarse…

46. A client in the cardiac unit is on a continuous telemetry monitor. The nurse observes the rhythm suddenly change to a wide-complex, rapid, regular rhythm at 180 bpm. The client is now unresponsive. What is the PRIORITY?

    • Administer antiarrhythmic medication immediately
    • Call for help immediately and start CPR — a pulseless client with a wide-complex tachycardia (likely ventricular tachycardia or ventricular fibrillation) is in cardiac arrest; CPR and defibrillation are the priority, not medication ✓
    • Obtain a 12-lead ECG before intervening
    • Increase the telemetry sensitivity

    PULSELESS VENTRICULAR TACHYCARDIA or VENTRICULAR FIBRILLATION is a shockable cardiac arrest rhythm requiring immediate CPR and defibrillation. RECOGNITION: Wide-complex tachycardia (QRS wider than 0.12 seconds) at 180 bpm + unresponsive client = likely PULSELESS VT or VF; do not waste time trying to…

47. A client post-op day 2 from abdominal surgery has a WBC of 16,800/mm³ (normal 4,500-10,500). The nurse should assess for which complication FIRST?

    • Hypertension
    • Wound infection or other post-operative infectious complication — elevated WBC in a post-op patient is a classic signal of infection that must be investigated by assessing the wound, vital signs, and any localising symptoms ✓
    • Dehydration
    • Pulmonary embolism

    ELEVATED WBC (LEUKOCYTOSIS) in a post-operative patient should trigger assessment for infection. NORMAL POST-SURGICAL WBC: A mild leukocytosis (WBC up to 12,000-15,000) is expected immediately after major surgery as part of the normal inflammatory response — this typically resolves within 24-48 hour…

48. A nurse is teaching a client newly prescribed warfarin (Coumadin). Which food interaction must the client understand?

    • Avoid all fruit juices while taking warfarin
    • Maintain a CONSISTENT intake of vitamin K-containing foods (leafy greens, broccoli, Brussels sprouts) — do not drastically increase or decrease them; sudden changes in vitamin K intake directly affect INR and anticoagulation effectiveness ✓
    • Increase green vegetables significantly to boost vitamin K
    • Vitamin K has no effect on warfarin dosing

    WARFARIN AND VITAMIN K INTERACTION is the most important dietary teaching for anticoagulated patients. MECHANISM: Warfarin works by blocking vitamin K-dependent clotting factors (II, VII, IX, X, Protein C and S); vitamin K in food COMPETES with warfarin's mechanism; more dietary vitamin K = lower an…

49. A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation. Their SpO₂ is 84% on room air. What oxygen delivery target should the nurse aim for?

    • SpO₂ 98-100% — maximum oxygenation
    • SpO₂ 88-92% using controlled oxygen delivery (nasal cannula at 1-2 L/min or Venturi mask at 24-28%) — COPD patients with chronic CO₂ retention may rely on hypoxic drive; high-flow oxygen can suppress ventilation ✓
    • No oxygen — COPD patients should not receive supplemental oxygen
    • SpO₂ 95% using a non-rebreather mask

    OXYGEN THERAPY IN COPD EXACERBATION requires understanding the hypoxic drive concept — though modern evidence has refined the approach. THE HYPOXIC DRIVE: Healthy individuals drive breathing by rising CO₂ levels (central chemo-receptors); COPD patients with chronic CO₂ retention become desensitised …

50. A client is admitted following a suspected opioid overdose. They have a respiratory rate of 6 breaths per minute, pinpoint pupils, and are barely responsive. What is the PRIORITY intervention?

    • Obtain a blood toxicology screen before treating
    • Administer naloxone (Narcan) and support respirations — naloxone is the antidote for opioid overdose; the clinical presentation (triad of respiratory depression, pinpoint pupils, decreased consciousness) is diagnostic; do not delay treatment to confirm with laboratory tests ✓
    • Administer flumazenil to reverse sedation
    • Position the client on their left side and observe

    OPIOID OVERDOSE is a life-threatening emergency with a specific antidote that must be administered rapidly. THE OPIOID OVERDOSE TRIAD: (1) Respiratory depression (rate below 12, here 6 — severely depressed); (2) Miosis (pinpoint pupils); (3) Altered/decreased consciousness. This classic triad is dia…

51. A nurse is monitoring a client receiving digoxin. Which finding would indicate possible digoxin toxicity?

    • Blood pressure of 120/80
    • Nausea, vomiting, visual disturbances (yellow-green halos), and bradycardia ✓
    • Heart rate of 80 bpm
    • Clear lung sounds

    DIGOXIN TOXICITY signs include: nausea, vomiting, anorexia; VISUAL DISTURBANCES (blurred or yellow-green vision, halos around lights); BRADYCARDIA (slow heart rate) and dysrhythmias; confusion, weakness. NCLEX physiological/pharmacology. Digoxin has a NARROW therapeutic range (0.5-2.0 ng/mL); toxici…

52. A client with type 1 diabetes is found to be diaphoretic, shaky, and confused with a blood glucose of 55 mg/dL. What is the priority intervention?

    • Administer insulin
    • Give a fast-acting carbohydrate (such as 15 g of glucose, juice, or glucose tablets) ✓
    • Encourage the client to exercise
    • Withhold all food

    This client has HYPOGLYCEMIA (blood glucose below 70 mg/dL with symptoms: diaphoresis, shakiness, confusion, tachycardia, hunger). The priority is to give a FAST-ACTING CARBOHYDRATE — about 15 grams (4 oz juice, glucose tablets, regular soda, or hard candy) if the client is CONSCIOUS and able to swa…

53. A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). What is the appropriate oxygen administration goal?

    • Administer high-flow oxygen to achieve 100% saturation
    • Administer low-flow oxygen to maintain oxygen saturation around 88-92%, monitoring closely ✓
    • Withhold all oxygen
    • Administer oxygen only at night

    For clients with COPD, administer LOW-FLOW oxygen to maintain SpO2 around 88-92% (target may vary, but lower than for other clients). NCLEX physiological/respiratory. RATIONALE: Some clients with chronic CO2 retention rely partly on a 'hypoxic drive' to breathe; giving HIGH concentrations of oxygen …

54. A client has a serum potassium level of 6.8 mEq/L (severe hyperkalemia). Which finding is the nurse's priority concern?

    • Mild headache
    • Cardiac dysrhythmias (such as peaked T waves progressing to dangerous arrhythmias) ✓
    • Dry skin
    • Increased appetite

    Severe HYPERKALEMIA (normal potassium 3.5-5.0 mEq/L) is a medical emergency because of its effect on the HEART — it causes CARDIAC DYSRHYTHMIAS. ECG changes progress: PEAKED T waves → widened QRS → and potentially fatal arrhythmias (ventricular fibrillation, cardiac arrest/asystole). NCLEX physiolog…

55. A nurse suspects a client is having a stroke. Using the acronym FAST, what does it stand for?

    • Fever, Aches, Sweating, Tiredness
    • Face drooping, Arm weakness, Speech difficulty, Time to call emergency services ✓
    • Fast, Active, Strong, Tall
    • Fatigue, Anxiety, Stress, Tension

    FAST is the stroke recognition acronym: F — FACE drooping (ask the person to smile; one side droops); A — ARM weakness (ask them to raise both arms; one drifts down); S — SPEECH difficulty (slurred or strange speech); T — TIME to call emergency services immediately (note the time symptoms started). …

56. A nurse is caring for a client with cirrhosis who develops confusion and asterixis (flapping tremor). The nurse recognizes these as signs of:

    • Normal recovery
    • Hepatic encephalopathy (caused by elevated ammonia levels) ✓
    • Improved liver function
    • Dehydration

    Confusion and ASTERIXIS (a flapping tremor of the hands) in a client with cirrhosis indicate HEPATIC ENCEPHALOPATHY — a complication caused by the failing liver's inability to clear AMMONIA (and other toxins) from the blood; elevated ammonia affects the brain, causing altered mental status, confusio…

57. A nurse is caring for a client with acute kidney injury. Which laboratory values would the nurse expect to be elevated?

    • Hemoglobin and hematocrit
    • Blood urea nitrogen (BUN) and creatinine ✓
    • Calcium and sodium
    • White blood cells only

    In ACUTE KIDNEY INJURY (AKI) or kidney failure, the kidneys can't filter waste, so BUN (blood urea nitrogen) and CREATININE rise (azotemia) — these are the primary markers of decreased kidney function. NCLEX physiological/renal. CREATININE is the more specific indicator of kidney function. OTHER cha…

58. A client is admitted with chest pain. Which laboratory test is most specific for diagnosing a myocardial infarction (heart attack)?

    • White blood cell count
    • Troponin (cardiac troponin I or T) ✓
    • Hemoglobin
    • Blood glucose

    TROPONIN (cardiac troponin I or T) is the MOST SPECIFIC and sensitive lab marker for myocardial infarction (heart attack). NCLEX physiological/cardiac. Troponin is released into the blood when heart muscle is damaged; it rises within a few hours of an MI, peaks, and stays elevated for days — making …

59. A nurse is caring for a client in a cast who reports severe, unrelenting pain, numbness, and the affected extremity is pale and cool. What complication should the nurse suspect?

    • Normal cast discomfort
    • Compartment syndrome (a medical emergency) ✓
    • Mild swelling
    • Improved circulation

    These findings (severe unrelenting pain out of proportion, numbness/tingling, pallor, coolness, and possibly pulselessness) suggest COMPARTMENT SYNDROME — a MEDICAL EMERGENCY where increased pressure within a muscle compartment compromises circulation and can cause permanent tissue/nerve damage or l…

60. A client is prescribed warfarin (an anticoagulant). Which laboratory value is monitored to assess its therapeutic effect?

    • Blood glucose
    • Prothrombin time (PT) and INR (international normalized ratio) ✓
    • Potassium level
    • Hemoglobin A1C

    WARFARIN (Coumadin) is monitored using PROTHROMBIN TIME (PT) and INR (international normalized ratio). NCLEX physiological/pharmacology. The therapeutic INR for most conditions is 2.0-3.0 (higher for some, e.g., mechanical heart valves). A too-high INR means increased bleeding risk; too-low means in…

61. A nurse is teaching a client how to use a metered-dose inhaler (MDI) with a bronchodilator and a corticosteroid inhaler. Which instruction is correct?

    • Use the corticosteroid first
    • Use the bronchodilator first, wait a few minutes, then use the corticosteroid; rinse the mouth after the corticosteroid ✓
    • Never rinse the mouth
    • Use both at the exact same time

    When using both a BRONCHODILATOR and a CORTICOSTEROID inhaler, use the BRONCHODILATOR FIRST (it opens the airways), wait a few minutes, THEN use the corticosteroid (so it reaches deeper into the now-open airways). NCLEX physiological/respiratory. RINSE THE MOUTH after using the CORTICOSTEROID inhale…

62. A nurse is caring for a client in diabetic ketoacidosis (DKA). What is the priority initial treatment?

    • Oral hypoglycemic agents
    • IV fluids (rehydration) and IV regular insulin, with electrolyte monitoring (especially potassium) ✓
    • Encourage the client to eat sugar
    • Withhold all fluids

    DIABETIC KETOACIDOSIS (DKA) — a life-threatening complication mainly of type 1 diabetes with hyperglycemia, ketosis, and metabolic acidosis — is treated with: (1) IV FLUIDS (the client is severely dehydrated — fluid replacement is a priority); (2) IV REGULAR INSULIN (the only insulin given IV — to l…

63. A nurse is caring for a client with heart failure. Which symptoms would indicate worsening fluid overload?

    • Weight loss and increased urination
    • Sudden weight gain, increased shortness of breath, edema, and crackles in the lungs ✓
    • Improved exercise tolerance
    • Decreased heart rate only

    Worsening HEART FAILURE / FLUID OVERLOAD signs include: SUDDEN WEIGHT GAIN (the most sensitive early indicator — fluid retention; a gain of 2-3 lbs in a day or 5 lbs in a week should be reported); increased SHORTNESS OF BREATH (dyspnea, orthopnea, paroxysmal nocturnal dyspnea); EDEMA (swelling, espe…

64. A nurse is caring for a client receiving chemotherapy who develops neutropenia (low neutrophil count). What is the priority nursing intervention?

    • Encourage visitors freely
    • Implement neutropenic precautions to protect the client from infection (strict hand hygiene, avoid crowds/sick people, no fresh flowers/raw produce per policy) ✓
    • Restrict fluids
    • Stop monitoring temperature

    NEUTROPENIA (abnormally low neutrophils, often from chemotherapy) severely weakens the immune system, making INFECTION the major life-threatening risk. The priority is NEUTROPENIC PRECAUTIONS (protective/reverse isolation) to protect the client: strict HAND HYGIENE; avoid crowds and people who are s…

65. A nurse is caring for a client with a nasogastric tube to suction who is at risk for which acid-base imbalance?

    • Respiratory acidosis
    • Metabolic alkalosis (from loss of stomach acid/hydrochloric acid) ✓
    • Respiratory alkalosis
    • No imbalance

    A client with prolonged NASOGASTRIC (NG) SUCTION or excessive VOMITING is at risk for METABOLIC ALKALOSIS — because they lose HYDROCHLORIC ACID (stomach acid, which contains H+ and chloride) from the stomach, raising blood pH (less acid = more alkaline). NCLEX physiological/acid-base. Also lost: pot…