NCLEX Practice Questions 3: Physiological Integrity Basic Care and Comfort

1. The nurses top priority when caring for a patient who uses a cane is:
A. Mobility
B. Rest periods
C. Nutritional deficits
D. Safety

2. A stage one decubitus ulcer will require all of the following except:
A. More frequent repositioning
B. Positioning that avoids the affected area
C. Scheduled massages to the affected site
D. Keeping the area clean and dry

3. A patient who has restraint orders necessary for their safety must:
A. Be provided diapers in case of incontinent episodes
B. Be released every two hours and repositioned
C. Be released, repositioned, ambulated, and taken to the bathroom at least every 4 hours
D. Be kept in bedclothes as they are more comfortable when restraints are necessary

4. ADL's, when performed by the patient, improve or maintain all of the following except:
A. Self esteem
B. Physical abilities
C. Communication
D. Mental acuity

5. Your patient has PVD (Peripheral Vascular Disease), and has stage 3 pitting edema in her lower legs and feet. What autonomous nursing action should you take?
A. Elevate her feet above the level of her heart.
B. Increase liquids to two liters per day.
C. Have the patient stand and walk more.
D. Encourage tight footwear to decrease swelling in her feet.

6. Pyrazinamide can cause inaccuracies in which of the following tests?
A. Thyroid function tests
B. CBC with differential
C. Liver function tests
D. Glucose tolerance test

7. A diabetic protects against ketoacidosis by:
A. Limiting food intake
B. Checking blood sugar four times a day
C. Checking blood sugar two times a day
D. Checking for ketones in the urine

8. Therapeutic massage helps relieve stress and:
A. Increases circulation and improves muscle tone
B. Assists the healing process in damaged tissue
C. Requires a physician's order
D. Improves memory

9. What medication can be given IV to decrease dysrhythmias by reducing irritability in the heart cells?
A. Potassium
B. Lidocaine
C. Digitalis
D. Procardia
Answers and Rational
1. Correct answer: D
Safety is the nurse's primary concern for a patient who is dependent on a cane for mobility.
A – Maintaining and improving mobility is important, but safety is the factor that will insure this.
B – Rest periods are a part of safety, not the primary concern.
C – There is no data that suggests a nutritional deficit, but a healthy intake is also part of the safety factor when ambulating.

2. Correct answer: C
Massaging and manipulation of the already damaged tissue will worsen the condition.
A – B – D are all true statements that will help the damaged skin heal.

3. Correct answer: C
Patients who are restrained must have the restraints removed at least every 4 hours to ambulate, reposition, toilet, and socialize. If the patient needs or asks to go to the bathroom in less than 4 hours, this need must be met. A continent patient who becomes incontinent because of restraints has been neglected and abused. Restrained patients are at greater risk for incontinent episodes, decubitus ulcers, loss of musculature, weakness, anxiety, and decreased mental acuity.
A – Providing diapers instead of releasing and assisting the patient to toilet is not acceptable nursing practice. It decreases the patient's dignity and violates patient's rights.
B – Every two hours is not required unless the patient has a need that dictates this action.
D – The patient who must be in restraints should have the same care and choices in their morning routine as an ambulatory patient. He/she should be groomed, dressed, and ready for their day.

4. Correct answer: C
A patient with a communication deficit does not usually improve with ADL independence.
A – The more the patients can accomplish for themselves, the more dignity is maintained and the less self-esteem issues will arise.
B – Activities of daily living provide much needed exercise, keeping joints and muscles limber and functional.
D – Patients who can attend to their own ADLs maintain mental acuity longer than those who are completely dependent. There should always be assistance close by, but allowing as much privacy and dignity as possible is very important to the patient's well-being.

5. Correct answer: A
Elevating the lower extremities will help vascular function drain the excess fluid and decrease swelling.
B – Increased liquids may amplify the problem, and needs a physician's order.
C – Standing will increase the edema.
D – Tight footwear can damage the edematous tissue.

6. Correct answer: C
Pyrazinamide, given for Tuberculosis, dramatically affects the liver and its enzymes.
A – This medication does not affect the thyroid test.
B – The CBC is unaffected by this medication.
D – The glucose tolerance test is not affected by Pyrazinamide.

7. Correct answer: B
Insulin dependent diabetics should take a blood sugar reading before each meal and before bed.
A – Limiting food intake can be dangerous for an insulin dependent diabetic.
C – Blood sugar must be taken 4 times a day.
D – Checking for ketones in the urine does not prevent ketoacidosis

8. Correct answer: A
Increasing circulation with a gentle massage has many therapeutic effects such as decreasing stress, increasing cognitive function, decreasing irritability, decreasing joint and muscle stiffness, and more.
B – Massage can further injure damaged tissue.
C – Normal gentle massage does not require a physician's order.
D – There is no evidence that massage can directly improve memory.

9. Correct answer: B
Lidocaine is given intravenously to MI patients many times to treat ventricular dysrhythmias.
A – Potassium does not have this mechanism of action and will not decrease the cellular irritability.
C – Digitalis slows and strengthens the heartbeat, and does not have the mechanism of action that is needed in this situation.
D – Procardia is a calcium channel blocker used for hypertensive patients or those with angina.