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NCLEX-RN Physiological Integrity Study
Guide | 6 Sub-Categories Covered | 250
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
1. A client with heart failure is receiving IV furosemide (Lasix). Which assessment finding
requires the nurse's immediate action?
A) Serum potassium level of 3.2 mEq/L
B) Urine output of 150 mL in the past 2 hours
C) Blood pressure of 138/88 mmHg
D) Weight loss of 1.5 kg (3.3 lbs) in 24 hours
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L is critically low. Furosemide is a
loop diuretic that wastes potassium, and hypokalemia can cause fatal cardiac
dysrhythmias. Option B (75 mL/hr) is adequate output. Option C is stable for a
heart failure client. Option D indicates the diuretic is working effectively.
2. A client with COPD has an ABG result of pH 7.30, PaCO2 58 mmHg, HCO3 26 mEq/L.
Which intervention should the nurse implement first?
A) Prepare for intubation
B) Administer oxygen via nasal cannula at 2 L/min
C) Place the client in high-Fowler's position
D) Notify the healthcare provider
Correct Answer: B
Rationale: The ABG shows respiratory acidosis (low pH, high PaCO2). Low-flow
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oxygen at 2 L/min is the priority to improve oxygenation without eliminating
the hypoxic drive in COPD clients. Positioning helps but is not first. Intubation is
a later step if oxygen fails.
3. A client is 6 hours post-total hip arthroplasty. Which finding requires immediate
provider notification?
A) Pain level of 6/10 at the surgical site
B) Urine output of 40 mL in the last hour
C) Unilateral calf swelling and redness
D) Temperature of 99.2°F (37.3°C)
Correct Answer: C
Rationale: Unilateral calf swelling, redness, and pain are classic signs of a deep
vein thrombosis (DVT). Post-hip surgery clients are at high risk for DVTs, which
can lead to a pulmonary embolism. Pain (A) is expected, urine output (B) is
adequate, and a low-grade temp (D) is common post-op.
4. The nurse is caring for a client receiving a continuous heparin infusion. Which
laboratory value indicates the therapy is therapeutic?
A) aPTT of 60 seconds
B) INR of 3.0
C) Platelet count of 80,000/mm³
D) PT of 22 seconds
Correct Answer: A
Rationale: For heparin therapy, the therapeutic aPTT is typically 1.5 to 2.5 times
the normal control (usually 60–80 seconds). INR (B) monitors warfarin therapy.
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Platelet count (C) is low and indicates possible heparin-induced
thrombocytopenia. PT (D) monitors warfarin or liver function.
5. A client with diabetes mellitus reports sweating, tremors, and palpitations. The nurse
checks the blood glucose and it is 52 mg/dL. What is the nurse's priority action?
A) Administer 50% dextrose IV push
B) Give 4 oz of orange juice orally
C) Recheck the blood glucose in 15 minutes
D) Notify the healthcare provider
Correct Answer: B
Rationale: For a conscious client with hypoglycemia (blood glucose <70 mg/dL),
the priority is to give 15 grams of rapid-acting carbohydrate (e.g., 4 oz juice, 3
glucose tablets). IV dextrose (A) is for unconscious clients. Rechecking (C) occurs
15 minutes after treatment. Notifying the provider (D) is not the immediate
priority.
6. A client is receiving a blood transfusion. Fifteen minutes after the start, the client
reports flank pain and chills. What is the nurse's priority action?
A) Slow the transfusion rate
B) Stop the transfusion and infuse normal saline
C) Administer diphenhydramine (Benadryl)
D) Notify the blood bank
Correct Answer: B
Rationale: Flank pain and chills indicate an acute hemolytic transfusion
reaction. The priority is to STOP the transfusion immediately, keep the IV line
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NCLEX-RN Physiological Integrity Study
Guide | 6 Sub-Categories Covered | 250
Questions And Well Graded Solutions With
Rationales Updated 2026-2027
1. A client with heart failure is receiving IV furosemide (Lasix). Which assessment finding
requires the nurse's immediate action?
A) Serum potassium level of 3.2 mEq/L
B) Urine output of 150 mL in the past 2 hours
C) Blood pressure of 138/88 mmHg
D) Weight loss of 1.5 kg (3.3 lbs) in 24 hours
Correct Answer: A
Rationale: A serum potassium of 3.2 mEq/L is critically low. Furosemide is a
loop diuretic that wastes potassium, and hypokalemia can cause fatal cardiac
dysrhythmias. Option B (75 mL/hr) is adequate output. Option C is stable for a
heart failure client. Option D indicates the diuretic is working effectively.
2. A client with COPD has an ABG result of pH 7.30, PaCO2 58 mmHg, HCO3 26 mEq/L.
Which intervention should the nurse implement first?
A) Prepare for intubation
B) Administer oxygen via nasal cannula at 2 L/min
C) Place the client in high-Fowler's position
D) Notify the healthcare provider
Correct Answer: B
Rationale: The ABG shows respiratory acidosis (low pH, high PaCO2). Low-flow
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oxygen at 2 L/min is the priority to improve oxygenation without eliminating
the hypoxic drive in COPD clients. Positioning helps but is not first. Intubation is
a later step if oxygen fails.
3. A client is 6 hours post-total hip arthroplasty. Which finding requires immediate
provider notification?
A) Pain level of 6/10 at the surgical site
B) Urine output of 40 mL in the last hour
C) Unilateral calf swelling and redness
D) Temperature of 99.2°F (37.3°C)
Correct Answer: C
Rationale: Unilateral calf swelling, redness, and pain are classic signs of a deep
vein thrombosis (DVT). Post-hip surgery clients are at high risk for DVTs, which
can lead to a pulmonary embolism. Pain (A) is expected, urine output (B) is
adequate, and a low-grade temp (D) is common post-op.
4. The nurse is caring for a client receiving a continuous heparin infusion. Which
laboratory value indicates the therapy is therapeutic?
A) aPTT of 60 seconds
B) INR of 3.0
C) Platelet count of 80,000/mm³
D) PT of 22 seconds
Correct Answer: A
Rationale: For heparin therapy, the therapeutic aPTT is typically 1.5 to 2.5 times
the normal control (usually 60–80 seconds). INR (B) monitors warfarin therapy.
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Platelet count (C) is low and indicates possible heparin-induced
thrombocytopenia. PT (D) monitors warfarin or liver function.
5. A client with diabetes mellitus reports sweating, tremors, and palpitations. The nurse
checks the blood glucose and it is 52 mg/dL. What is the nurse's priority action?
A) Administer 50% dextrose IV push
B) Give 4 oz of orange juice orally
C) Recheck the blood glucose in 15 minutes
D) Notify the healthcare provider
Correct Answer: B
Rationale: For a conscious client with hypoglycemia (blood glucose <70 mg/dL),
the priority is to give 15 grams of rapid-acting carbohydrate (e.g., 4 oz juice, 3
glucose tablets). IV dextrose (A) is for unconscious clients. Rechecking (C) occurs
15 minutes after treatment. Notifying the provider (D) is not the immediate
priority.
6. A client is receiving a blood transfusion. Fifteen minutes after the start, the client
reports flank pain and chills. What is the nurse's priority action?
A) Slow the transfusion rate
B) Stop the transfusion and infuse normal saline
C) Administer diphenhydramine (Benadryl)
D) Notify the blood bank
Correct Answer: B
Rationale: Flank pain and chills indicate an acute hemolytic transfusion
reaction. The priority is to STOP the transfusion immediately, keep the IV line
