NCLEX-RN
RN Physiological Integrity Reduction of Risk Potential Questions
Extract:
Question 1 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 2 of 5
A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate the client is experiencing side effects of the thyroid replacement therapy? Select all that apply.
Correct Answer: A,D
Rationale: Excessive sweating (
A) and leg cramps (
D) suggest hyperthyroidism from overmedication. Constipation (
B) and cold intolerance (
C) indicate under-treatment.
Question 3 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 4 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 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).