Best Solutions All Correct Answers with Explanation Graded A Physiological Integrity

Best Solutions All Correct Answers with Explanation (Graded A+) Physiological Integrity Practice Test 2 (NCLEX-RN) – for Registered Nurses

• A patient is taking daily low-dose aspirin and experiences prolonged bleeding from a

superficial cut. Which of the following lab results would be expected for this patient?

• Prothrombin time (PT) 14 seconds
• Activated partial thromboplastin time (aPTT) 30 seconds
• Bleeding time of 8 minutes (ANSWER)
• Platelets 150 x 10^9/L

EXPLANATION: During primary hemostasis, a platelet plug is formed. Clotting factors are involved in secondary hemostasis (coagulation). Both aPTT and PT measure the coagulation pathways. Aspirin inhibits cyclooxygenase (COX) which promotes the synthesis of TXA_2.Because TXA_2 is necessary for platelet aggregation, primary hemostasis is inhibited. This is measured by bleeding time. Platelet activity is affected, but not the number of platelets.

• The clinic nurse is providing pre-operative instructions to a client. When reviewing the

client's current medications, which one should the nurse advise the client to discontinue 5-7 days before surgery?

• Venlafaxine (Effexor)
• Montelukast (Singulair)
• Warfarin (Coumadin) (ANSWER)
• Famotidine (Pepcid)

EXPLANATION: To decrease the risk of hemorrhage, the client should stop long-term warfarin (Coumadin) therapy 5-7 days prior to surgery. The provider will determine the exact number of days, as well as if the client will be placed on heparin. The other medications will be held with the usual NPO pre-op order by the provider. Venlafaxine (Effexor) is an anti-depressant; Famotidine (Pepcid) reduces stomach acid; Montelukast (Singulair) is an asthma medication.

• When a client is hospitalized with a deep vein thrombosis (DVT), which of the following

nursing interventions is appropriate?

• Ambulate slowly every 8 hours for 10 minutes.
• Elevate the affected leg above the heart. (ANSWER)
• Do range-of-motion exercises for both legs.
• Apply cold compresses to the affected leg.

EXPLANATION: Treatment for a DVT involves bed rest to avoid dislodging the clot; applying warm heat to reduce leg swelling, and elevating the affected leg, or both legs. Other nursing interventions include application of thigh-high TED hose, range-of-motion for the unaffected leg; vital signs q 4-6 hrs; administering heparin as ordered; and monitoring for complications of pulmonary embolism (PE), such as shortness of breath, chest pain, apprehension, cough, hemoptysis, tachypnea, crackles, tachycardia, diaphoresis, and fever.

• With a stroke patient, what is the best position for insertion of a nasogastric (NG) tube?
• Supine
• High Fowler's (ANSWER)
• Trendelenburg
• Low Fowler's

EXPLANATION: High Fowler's position is the best position to avoid aspiration. Have an emesis basin and suction equipment nearby, since tube insertion can cause temporary nausea.

• The healthcare provider administers NPH insulin at 6:00 AM to a patient with diabetes.

How soon will the patient show any signs of hypoglycemia?

a. 7:00 AM

b. 9:00 AM

c. 8:00 AM

d. 10:00 AM (ANSWER)

EXPLANATION: NPH insulin is an intermediate-acting insulin, usually given once or twice a day. The peak effect of NPH insulin occurs 4-12 hours after administration, so the nurse should begin to monitor for signs of hypoglycemia at 10:00 AM. Hypoglycemia (blood glucose below 70mg/dl) can have a rapid onset. Signs include shakiness, dizziness, anxiety, confusion, sweating, chills, and clammy skin. The patient's pulse may increase. The patient may complain of blurred vision, headache, fatigue, hunger, or nausea.

• The nurse is educating a client with chronic kidney disease (CKD) about the need to

restrict potassium in their diet. Which of the following statements by the client indicates a need for further instruction?

• "I will choose sherbet instead of ice cream."
• "I'll cook with onions instead of tomatoes."
• "I will have an apple instead of a banana."
• "I can eat peanuts instead of popcorn." (ANSWER)

EXPLANATION: In chronic kidney disease (CKD), the kidneys are unable to filter potassium, leading to hyperkalemia. Stage 5 CKD, also called end-stage renal disease (ESRD), requires dialysis. Between dialysis treatments, clients must carefully monitor potassium intake. They should avoid dairy products, nuts and seeds, salt substitutes, fruits and vegetables that are naturally high in potassium, and chocolate. Legumes that are high in potassium include peanuts, soy beans, lentils, kidney beans, pinto beans, and lima beans. Unsalted popcorn is allowed.

• For a patient who is in the late stages of chronic bronchitis, which of the following

would indicate the patient has developed cor pulmonale?

• Night sweats
• Hypocapnia
• Hepatomegaly (ANSWER)
• Venous stasis ulcers

EXPLANATION: Cor pulmonale, or right-sided heart failure, is the result of a lung condition, such as chronic bronchitis or COPD. The diseased lungs deliver less oxygen to the right

ventricle, putting a strain on the heart from pulmonary hypertension. Over time, the right ventricle fails, causing increased venous pressure and liver enlargement (hepatomegaly).Common early symptoms include fatigue, tachypnea, shortness of breath on exertion, and a cough.

• The nurse in the Emergency Department assesses a client for a possible fractured rib.

Which of the following characteristics will support the suspected diagnosis?

• Pain on inspiration, with shallow, guarded respirations (ANSWER)
• Pain on expiration, with deep, rapid respirations
• Pain on inspiration, with deep, rapid respirations
• Pain on expiration, with shallow, guarded respirations

EXPLANATION: A client with a fractured rib will complain of pain on inspiration, or when moving or coughing. There is also pain when the site is palpated. Respirations will be shallow and guarded; it will be nearly impossible for the client to take a deep breath. There may also be shortness of breath, as well as bruising at the site.

• A nurse's neighbor tells the nurse that their provider recommended that the neighbor

take docusate sodium (Colace). Which of the following statements by the nurse is correct?

• "You'll probably feel less anxious very soon."
• "Your heartburn is going to go away."
• "You may experience mild headaches at first."
• "You'll have regular bowel movements." (ANSWER)

EXPLANATION: Docusate is an emollient laxative that is prescribed to treat occasional constipation. It works by increasing absorption of water, leading to a soft stool. It is an over-the- counter (OTC) medication. The nurse can also suggest that the neighbor increase fluid intake when using docusate. The other options are incorrect.