NCLEX-RN
RN Physiological Integrity Reduction of Risk Potential Questions
Question 1 of 5
A nurse in intensive coronary care is caring for a client with an endotracheal tube who underwent coronary bypass surgery. The client awakens and attempts to communicate. Which nursing interventions should the nurse perform? Select all that apply.
Correct Answer: A,B
Rationale: A communication board (
A) and yes/no questions (
B) facilitate communication for a client with an endotracheal tube. Open-ended questions (
C) are difficult, and an electrolarynx (
D) is for laryngeal issues.
Question 2 of 5
A college student presents at the emergency department after being thrown off a horse. Head injury with increased intracranial pressure (ICP) is suspected. The nurse understands that late signs of increased ICP include which manifestations? Select all that apply.
Correct Answer: A,E,F
Rationale: Late signs of increased ICP include seizures (
A), severe headache (E), and nausea/vomiting (F) due to brain compression. Irritability, restlessness, and disorientation are earlier signs.
Question 3 of 5
The nurse is caring for a client receiving warfarin therapy for atrial fibrillation. Laboratory results show an INR of 3.9. The nurse would expect which order from the health care provider?
Correct Answer: B
Rationale: INR 3.9 is above the therapeutic range (2-3 for atrial fibrillation), requiring a dose decrease (
B). Protamine sulfate (
C) is for heparin reversal.
Question 4 of 5
The nurse is teaching a newly admitted client about fall prevention. The nurse understands that which of the following interventions can help prevent client falls? Select all that apply.
Correct Answer: A,B,E
Rationale: Keeping articles within reach (
A), explaining the call light (
B), and reminding to call for assistance (E) reduce fall risk. All side rails up (
C) can increase risk, and dim lights (
D) impair visibility.
Question 5 of 5
The nurse is reviewing labs of a newly admitted client. Which lab result would prompt the nurse to contact the health care provider?
Correct Answer: B
Rationale: BNP 760 pg/mL indicates heart failure, requiring prompt provider notification. Other values are within normal ranges (ALT 7-56, WBC 4,000-11,000, direct bilirubin 0-0.3).