NCLEX: Physiological
Integrity With Answers Focus
On Your Success
A nurse is checking a client's disposable closed chest drainage system at the beginning of the
shift and notes continuous bubbling in the water-seal chamber. The nurse interprets this
observation as indicating which of the following?
1. The system is intact
2. A client's pneumothorax is resolving
3. The suction to the system is shut off
4. There is an air leak somewhere in the system
4. There is an air leak somewhere in the system
A client has a Mantoux skin test done. The results indicate an area of induration that is 8mm in
size. The nurse should make which interpretation based on this finding?
1. The client has active tuberculosis
2. The client has a negative response
3. the client has a history of tuberculosis
4. the client has been exposed to tuberculosis
2. The client has a negative response
A client being seen in the ambulatory care clinic has a history of being treated for syphilis
infection. The nurse determines that the client has been reinfected if which of the following
characteristics is noted in a penile lesion?
1. Popular areas and erythema
2. Cauliflower-like appearance
3. Induration and absence of pain
4. Multiple vesicles, with some that have ruptured
3. Induration and absence of pain
,A nurse should review the laboratory results of a client with Cushing syndrome for which
characteristic manifestations?
1. Hypokalemia
2. Hyperglycemia
3. Decreased plasma cortisol levels
4. Low white blood cell count
2. Hyperglycemia
Quinidine gluconate is prescribed for a client. The nurse reviews the client's medical history for
which condition is a contraindication in the use of this medication.
1. Asthma
2. Infection
3. Muscle weakness
4. Complete atrioventricular block
4. Complete atrioventricular block
A client with glomerulonephritis is at risk of developing acute renal failure. The nurse should
monitor the client for which of the following signs of this complication?
1. Bradycardia
2. Hypertension
3. Decreased cardiac output
4. Decreased central venous pressure
2. Hypertension
A nurse is developing a plan of care for a client placed in Buck extension traction after a hip
fracture. The nurse determines that the priority consideration in caring for the client receiving
this treatment is which of the following?
1. Lack of diversion of all activity as a result of bed rest
2. Difficulty with bathing and other self-care measures because of the need for traction
3. Lack of mobility as a result of the traction device
4. Difficulty with social interactions because of the need for traction
3. Lack of mobility as a result of the traction device
,A nurse is monitoring a client with abruptio placental for signs of disseminated intravascular
coagulopathy (DIC). Which of the following signs would indicate the occupancy of DIC?
1. Pain and swelling of the calf of one leg
2. Rapid clotting lines
3. An increased platelet count
4. Petechiae, oozing from injection sites, and hematuria
4. Petechiae, oozing from injection sites, and hematuria
The results of a nonstress stress test are documented in the chart as "no accelerations during a 40-
minute observation." The nurse interprets these findings as which of the following?
1. A reactive nonstress test
2. A nonreactive nonstress test
3. Equivocal
4. Unsatisfactory
2. A nonreactive nonstress test
A client complains of pain in the mouth 10 days after receiving chemotherapy. Which of the
following should the nurse address as a priority?
1. Inadequate nutritional intake
2. Presence of skin breakdown
3. The client complains of pain
4. Increased susceptibility to infection
3. The client complains of skin breakdown
A nurse is caring for a client with a history of mild heart failure who is receiving diltiazem
hydrochloride (Cardizem) for hypertension. The nurse should assess the client for which of the
following signs while the client is receiving this therapy?
1. Bradycardia
2. Wheezing
3. Peripheral edema and weight gain
4. Apical pulse rate lower than baseline
3. Peripheral edema and weight gain
, A nurse should monitor a client after myocardial infarction for which signs that are indicative of
cardiogenic shock.
1. Bradycardia, hypertension, and a pale appearance
2. Peripheral edema, distended neck veins, and hepatic engorgement
3. Tachycardia, confusion, and hypotension
4. Oliguria, bradypnea, and warm dry skin
3. Tachycardia, confusion, and hypotension
A nurse expects a client experiencing an acute myocardial infarction to first manifest which of
the following patterns on the electrocardiography?
1. An abnormal Q wave
2. ST-segment elevation
3. T wave elevation
4. Absent P waves
2. ST-segment elevation
A client has undergone urinary diversion after cystectomy for bladder cancer. The nurse assesses
the client's urostomy stoma to ensure that it shows which of the following characteristics?
1. It's pale and pink
2. It's pink and dry
3. It's red and moist
4. It is dusky to beefy colored
3. It's red and moist
A nurse assessing a female client with Cushing syndrome expects to note which of the
following?
1. Hirsutism
2. Hypotension
3. Hypoglycemia
4. Pallor
1. Hirutism
Integrity With Answers Focus
On Your Success
A nurse is checking a client's disposable closed chest drainage system at the beginning of the
shift and notes continuous bubbling in the water-seal chamber. The nurse interprets this
observation as indicating which of the following?
1. The system is intact
2. A client's pneumothorax is resolving
3. The suction to the system is shut off
4. There is an air leak somewhere in the system
4. There is an air leak somewhere in the system
A client has a Mantoux skin test done. The results indicate an area of induration that is 8mm in
size. The nurse should make which interpretation based on this finding?
1. The client has active tuberculosis
2. The client has a negative response
3. the client has a history of tuberculosis
4. the client has been exposed to tuberculosis
2. The client has a negative response
A client being seen in the ambulatory care clinic has a history of being treated for syphilis
infection. The nurse determines that the client has been reinfected if which of the following
characteristics is noted in a penile lesion?
1. Popular areas and erythema
2. Cauliflower-like appearance
3. Induration and absence of pain
4. Multiple vesicles, with some that have ruptured
3. Induration and absence of pain
,A nurse should review the laboratory results of a client with Cushing syndrome for which
characteristic manifestations?
1. Hypokalemia
2. Hyperglycemia
3. Decreased plasma cortisol levels
4. Low white blood cell count
2. Hyperglycemia
Quinidine gluconate is prescribed for a client. The nurse reviews the client's medical history for
which condition is a contraindication in the use of this medication.
1. Asthma
2. Infection
3. Muscle weakness
4. Complete atrioventricular block
4. Complete atrioventricular block
A client with glomerulonephritis is at risk of developing acute renal failure. The nurse should
monitor the client for which of the following signs of this complication?
1. Bradycardia
2. Hypertension
3. Decreased cardiac output
4. Decreased central venous pressure
2. Hypertension
A nurse is developing a plan of care for a client placed in Buck extension traction after a hip
fracture. The nurse determines that the priority consideration in caring for the client receiving
this treatment is which of the following?
1. Lack of diversion of all activity as a result of bed rest
2. Difficulty with bathing and other self-care measures because of the need for traction
3. Lack of mobility as a result of the traction device
4. Difficulty with social interactions because of the need for traction
3. Lack of mobility as a result of the traction device
,A nurse is monitoring a client with abruptio placental for signs of disseminated intravascular
coagulopathy (DIC). Which of the following signs would indicate the occupancy of DIC?
1. Pain and swelling of the calf of one leg
2. Rapid clotting lines
3. An increased platelet count
4. Petechiae, oozing from injection sites, and hematuria
4. Petechiae, oozing from injection sites, and hematuria
The results of a nonstress stress test are documented in the chart as "no accelerations during a 40-
minute observation." The nurse interprets these findings as which of the following?
1. A reactive nonstress test
2. A nonreactive nonstress test
3. Equivocal
4. Unsatisfactory
2. A nonreactive nonstress test
A client complains of pain in the mouth 10 days after receiving chemotherapy. Which of the
following should the nurse address as a priority?
1. Inadequate nutritional intake
2. Presence of skin breakdown
3. The client complains of pain
4. Increased susceptibility to infection
3. The client complains of skin breakdown
A nurse is caring for a client with a history of mild heart failure who is receiving diltiazem
hydrochloride (Cardizem) for hypertension. The nurse should assess the client for which of the
following signs while the client is receiving this therapy?
1. Bradycardia
2. Wheezing
3. Peripheral edema and weight gain
4. Apical pulse rate lower than baseline
3. Peripheral edema and weight gain
, A nurse should monitor a client after myocardial infarction for which signs that are indicative of
cardiogenic shock.
1. Bradycardia, hypertension, and a pale appearance
2. Peripheral edema, distended neck veins, and hepatic engorgement
3. Tachycardia, confusion, and hypotension
4. Oliguria, bradypnea, and warm dry skin
3. Tachycardia, confusion, and hypotension
A nurse expects a client experiencing an acute myocardial infarction to first manifest which of
the following patterns on the electrocardiography?
1. An abnormal Q wave
2. ST-segment elevation
3. T wave elevation
4. Absent P waves
2. ST-segment elevation
A client has undergone urinary diversion after cystectomy for bladder cancer. The nurse assesses
the client's urostomy stoma to ensure that it shows which of the following characteristics?
1. It's pale and pink
2. It's pink and dry
3. It's red and moist
4. It is dusky to beefy colored
3. It's red and moist
A nurse assessing a female client with Cushing syndrome expects to note which of the
following?
1. Hirsutism
2. Hypotension
3. Hypoglycemia
4. Pallor
1. Hirutism
