NCLEX-RN
NCLEX RN Physiological Integrity Questions
Extract:
Question 1 of 5
The nurse is teaching a newly diagnosed client about Guillain-Barré syndrome (GBS). What information would the nurse provide in her teaching? Select all that apply.
Correct Answer: C,D,E
Rationale: GBS is self-limiting with temporary paralysis (
C), causes muscle weakness/paralysis (
D), and is linked to infections like Epstein-Barr (E). It affects males slightly more (
A), and the acute phase lasts weeks to months (
B).
Question 2 of 5
A 47-year-old client presents to the emergency department with severe hypotension, muscle weakness, fatigue, and vomiting. Labs reveal a potassium level of 6.1 mEq/L and a sodium level of 128 mEq/L. Which of the following should the nurse anticipate for this client?
Correct Answer: C
Rationale: Symptoms and labs suggest Addisonian crisis (hypotension, hyperkalemia, hyponatremia). IV saline, dextrose, and hydrocortisone (
C) stabilize the client. Spironolactone (
A) worsens hyperkalemia, Lactated Ringer's (
B) is less specific, and potassium (
D) is contraindicated.
Question 3 of 5
The nurse is performing hemodialysis on a client, with the understanding that air embolus is a complication of this treatment. Which assessment findings by the nurse indicate an air embolus?
Correct Answer: B
Rationale: Air embolus during hemodialysis causes chest pain and anxiety (
B) due to air blocking pulmonary circulation. Cold intolerance (
A), decreased respirations (
C), and hypertension (
D) are not typical signs.
Question 4 of 5
While in a restaurant the nurse notices a woman clutching her throat. The woman is unable to speak. The nurse asks the woman if she's choking, and she indicates yes. Which response by the nurse should be done first?
Correct Answer: D
Rationale: The Heimlich maneuver (
D) is the first action for choking to dislodge the obstruction. Chin tilt (
A) and breaths (
C) are for unconscious patients, and chest compressions (
B) are for cardiac arrest.
Question 5 of 5
A client is brought to the ED following a drowning event. The nurse assigned to the client understands that which is true regarding drowning?
Correct Answer: C
Rationale: Determining the cause of drowning (
C) identifies underlying conditions like seizures for follow-up. Cold water may improve outcomes (
A), aspiration reduces surfactant (
B), and contaminants worsen lung injury (
D).