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NCLEX RN· Physiological Adaptation · NCLEX RN Physiological Integrity

Full Question & Rationale Repository

Showing all 5 practice questions with expert explanatory rationales.

Question 1 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?

A. Drowning in very cold water causes a worse outcome for the client than drowning in warmer water.

B. Aspiration of both salt and fresh water increases surfactant in the lungs and leads to increased lung compliance.

C. If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment.

D. Contaminants in the water such as microbes, mud, chemicals, and algae do not affect the degree of injury to the lungs.

Expert Explanatory Rationale

Correct Answer: If possible, the cause of drowning should be determined in order to know if the client suffered a medical condition such as a seizure that requires follow-up treatment.

Question 2 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?

A. establish an airway by tilting the chin back

B. administer five quick chest compressions

C. administer two rescue breaths

D. perform the Heimlich maneuver

Expert Explanatory Rationale

Correct Answer: perform the Heimlich maneuver

Question 3 of 5

The nurse is reviewing morning labs for a client. Which lab value requires immediate intervention by the nurse?

A. calcium 9.8 mg/dL

B. sodium 137 mEq/L

C. chloride 104 mEq/L

D. potassium 3.1 mEq/L

Expert Explanatory Rationale

Correct Answer: potassium 3.1 mEq/L

Question 4 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?

A. administration of IV spironolactone

B. boluses of Lactated Ringer's to increase blood pressure

C. administration of IV saline, dextrose, or hydrocortisone

D. boluses of 0.45% normal saline with 40 mEq/L of potassium

Expert Explanatory Rationale

Correct Answer: administration of IV saline, dextrose, or hydrocortisone

Question 5 of 5

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes. Which should the nurse include in her teaching?

A. check the feet daily

B. have eye examinations every 2 years

C. use a heating pad to keep the feet warm

D. take extra insulin before consuming sweets

Expert Explanatory Rationale

Correct Answer: check the feet daily

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