NCLEX RN Physiological Adaptation
Exam 3 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with hypovolemic shock has a blood pressure of 82/48 mm
Hg, heart rate of 128/min, and cool, clammy skin. Which intervention
should the nurse implement first?
A. Administer prescribed opioid analgesic
B. Place the client in a high-Fowler position
C. Begin rapid administration of prescribed isotonic IV fluids
D. Restrict oral and IV fluids
Rationale: Hypovolemic shock requires rapid restoration of circulating
volume. Isotonic fluids such as normal saline or lactated Ringer solution
are commonly used initially.
2. A client with septic shock is receiving IV fluids. Which finding
indicates worsening tissue perfusion?
A. Warm skin
B. Heart rate of 92/min
C. Urine output of 15 mL/hr
D. Blood pressure of 110/70 mm Hg
Rationale: Urine output below approximately 30 mL/hr in an adult can
indicate inadequate renal perfusion.
3. A client develops anaphylaxis after receiving an antibiotic. Which
medication should the nurse administer first?
A. Diphenhydramine
,B. Methylprednisolone
C. Albuterol
D. Epinephrine
Rationale: IM epinephrine is the first-line treatment for anaphylaxis
because it rapidly reverses airway edema, bronchospasm, and
vasodilation.
4. Which finding in a client with anaphylaxis requires immediate
intervention?
A. Urticaria
B. Pruritus
C. Facial flushing
D. Stridor
Rationale: Stridor indicates upper-airway obstruction and can rapidly
progress to respiratory failure.
5. A client with cardiogenic shock has pulmonary crackles and severe
dyspnea. Which intervention is most appropriate?
A. Administer a large fluid bolus
B. Administer prescribed oxygen and prepare for cardiac-support
medications
C. Encourage oral fluids
D. Place the client flat
Rationale: Cardiogenic shock results from inadequate cardiac pumping.
Excessive fluid can worsen pulmonary edema.
6. A client with acute heart failure suddenly develops pink, frothy
sputum. What should the nurse do first?
A. Encourage ambulation
B. Administer oral fluids
,C. Place the client in high-Fowler position and administer oxygen
D. Lower the head of the bed
Rationale: Pink, frothy sputum suggests acute pulmonary edema.
Upright positioning and oxygen improve ventilation and oxygenation.
7. Which assessment finding is most concerning in a client with
pulmonary embolism?
A. Mild anxiety
B. Temperature of 37.4°C (99.3°F)
C. Sudden severe dyspnea and oxygen saturation of 84%
D. Respiratory rate of 20/min
Rationale: Acute hypoxemia with severe dyspnea is characteristic of a
potentially life-threatening pulmonary embolism.
8. A client with suspected pulmonary embolism is receiving oxygen.
Which position is best?
A. Prone
B. Supine
C. Semi-Fowler or high-Fowler
D. Trendelenburg
Rationale: Upright positioning promotes lung expansion and can
improve oxygenation.
9. A client with a tension pneumothorax is becoming hypotensive and
severely dyspneic. Which intervention should the nurse anticipate?
A. Oral antibiotics
B. Incentive spirometry
C. Emergency needle decompression
D. Fluid restriction
Rationale: Tension pneumothorax causes life-threatening pressure
buildup and requires immediate decompression.
, 10. Which finding is expected with a tension pneumothorax?
A. Bilateral equal breath sounds
B. Bradycardia
C. Absent breath sounds on the affected side
D. Productive cough
Rationale: Air under pressure collapses the affected lung, causing
markedly diminished or absent breath sounds.
11. A client with severe asthma suddenly has minimal wheezing despite
worsening respiratory distress. What does this finding indicate?
A. Improvement
B. Effective bronchodilation
C. Severe airway obstruction with minimal air movement
D. Resolution of inflammation
Rationale: A “silent chest” can indicate critically reduced airflow and
impending respiratory failure.
12. Which finding indicates that a client with asthma is deteriorating?
A. Peak flow increasing
B. Respiratory rate decreasing to 18/min
C. Increasing fatigue and difficulty speaking
D. Oxygen saturation of 98%
Rationale: Fatigue and inability to speak in complete sentences indicate
severe respiratory compromise.
13. A client with COPD has chronic carbon dioxide retention. Which
oxygen prescription should the nurse question?
A. Oxygen at 1 L/min by nasal cannula
B. Oxygen at 2 L/min by nasal cannula
C. Oxygen at 15 L/min by nonrebreather mask without further
Exam 3 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with hypovolemic shock has a blood pressure of 82/48 mm
Hg, heart rate of 128/min, and cool, clammy skin. Which intervention
should the nurse implement first?
A. Administer prescribed opioid analgesic
B. Place the client in a high-Fowler position
C. Begin rapid administration of prescribed isotonic IV fluids
D. Restrict oral and IV fluids
Rationale: Hypovolemic shock requires rapid restoration of circulating
volume. Isotonic fluids such as normal saline or lactated Ringer solution
are commonly used initially.
2. A client with septic shock is receiving IV fluids. Which finding
indicates worsening tissue perfusion?
A. Warm skin
B. Heart rate of 92/min
C. Urine output of 15 mL/hr
D. Blood pressure of 110/70 mm Hg
Rationale: Urine output below approximately 30 mL/hr in an adult can
indicate inadequate renal perfusion.
3. A client develops anaphylaxis after receiving an antibiotic. Which
medication should the nurse administer first?
A. Diphenhydramine
,B. Methylprednisolone
C. Albuterol
D. Epinephrine
Rationale: IM epinephrine is the first-line treatment for anaphylaxis
because it rapidly reverses airway edema, bronchospasm, and
vasodilation.
4. Which finding in a client with anaphylaxis requires immediate
intervention?
A. Urticaria
B. Pruritus
C. Facial flushing
D. Stridor
Rationale: Stridor indicates upper-airway obstruction and can rapidly
progress to respiratory failure.
5. A client with cardiogenic shock has pulmonary crackles and severe
dyspnea. Which intervention is most appropriate?
A. Administer a large fluid bolus
B. Administer prescribed oxygen and prepare for cardiac-support
medications
C. Encourage oral fluids
D. Place the client flat
Rationale: Cardiogenic shock results from inadequate cardiac pumping.
Excessive fluid can worsen pulmonary edema.
6. A client with acute heart failure suddenly develops pink, frothy
sputum. What should the nurse do first?
A. Encourage ambulation
B. Administer oral fluids
,C. Place the client in high-Fowler position and administer oxygen
D. Lower the head of the bed
Rationale: Pink, frothy sputum suggests acute pulmonary edema.
Upright positioning and oxygen improve ventilation and oxygenation.
7. Which assessment finding is most concerning in a client with
pulmonary embolism?
A. Mild anxiety
B. Temperature of 37.4°C (99.3°F)
C. Sudden severe dyspnea and oxygen saturation of 84%
D. Respiratory rate of 20/min
Rationale: Acute hypoxemia with severe dyspnea is characteristic of a
potentially life-threatening pulmonary embolism.
8. A client with suspected pulmonary embolism is receiving oxygen.
Which position is best?
A. Prone
B. Supine
C. Semi-Fowler or high-Fowler
D. Trendelenburg
Rationale: Upright positioning promotes lung expansion and can
improve oxygenation.
9. A client with a tension pneumothorax is becoming hypotensive and
severely dyspneic. Which intervention should the nurse anticipate?
A. Oral antibiotics
B. Incentive spirometry
C. Emergency needle decompression
D. Fluid restriction
Rationale: Tension pneumothorax causes life-threatening pressure
buildup and requires immediate decompression.
, 10. Which finding is expected with a tension pneumothorax?
A. Bilateral equal breath sounds
B. Bradycardia
C. Absent breath sounds on the affected side
D. Productive cough
Rationale: Air under pressure collapses the affected lung, causing
markedly diminished or absent breath sounds.
11. A client with severe asthma suddenly has minimal wheezing despite
worsening respiratory distress. What does this finding indicate?
A. Improvement
B. Effective bronchodilation
C. Severe airway obstruction with minimal air movement
D. Resolution of inflammation
Rationale: A “silent chest” can indicate critically reduced airflow and
impending respiratory failure.
12. Which finding indicates that a client with asthma is deteriorating?
A. Peak flow increasing
B. Respiratory rate decreasing to 18/min
C. Increasing fatigue and difficulty speaking
D. Oxygen saturation of 98%
Rationale: Fatigue and inability to speak in complete sentences indicate
severe respiratory compromise.
13. A client with COPD has chronic carbon dioxide retention. Which
oxygen prescription should the nurse question?
A. Oxygen at 1 L/min by nasal cannula
B. Oxygen at 2 L/min by nasal cannula
C. Oxygen at 15 L/min by nonrebreather mask without further
