NCLEX RN Physiological Adaptation
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A client with acute pulmonary edema is severely dyspneic and has an
oxygen saturation of 82% on room air. Which action should the nurse
take first?
A. Obtain a chest x-ray
B. Place the client in high-Fowler’s position
C. Administer a prescribed diuretic
D. Restrict oral fluids
Answer: Place the client in high-Fowler’s position.
Rationale: Positioning the client upright promotes maximum lung expansion
and decreases venous return to the heart, helping improve oxygenation
rapidly.
2. A client with diabetic ketoacidosis (DKA) has a blood glucose of 620
mg/dL and hypotension. Which prescription should the nurse implement
first?
A. IV regular insulin
B. IV potassium replacement
C. 0.9% sodium chloride infusion
D. Sodium bicarbonate administration
Answer: 0.9% sodium chloride infusion.
,Rationale: Severe dehydration and hypovolemia are major problems in DKA.
Initial treatment generally focuses on restoring circulating volume with
isotonic fluid before or along with insulin therapy.
3. A client with a tension pneumothorax develops severe respiratory
distress, hypotension, and absent breath sounds on one side. Which
intervention is the priority?
A. Obtain a sputum specimen
B. Prepare for emergency needle decompression
C. Encourage coughing and deep breathing
D. Administer oral antibiotics
Answer: Prepare for emergency needle decompression.
Rationale: Tension pneumothorax can rapidly cause cardiovascular collapse.
Immediate decompression is required to relieve pressure and restore
ventilation and circulation.
4. A client with heart failure reports increasing shortness of breath and has
bilateral crackles. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Respiratory rate of 28/min
C. Oxygen saturation of 84%
D. Weight gain of 2 kg in 1 week
Answer: Oxygen saturation of 84%.
Rationale: Severe hypoxemia represents an immediate threat to life and
requires prompt intervention to improve oxygenation.
5. A client with a suspected myocardial infarction reports crushing
substernal chest pain. Which finding is most concerning?
A. Heart rate of 96/min
B. Blood pressure of 108/68 mm Hg
C. New-onset ventricular dysrhythmia
D. Mild nausea
,Answer: New-onset ventricular dysrhythmia.
Rationale: Ventricular dysrhythmias can rapidly deteriorate into ventricular
tachycardia or ventricular fibrillation and are a major complication of acute
myocardial infarction.
6. A client with a traumatic head injury becomes increasingly drowsy and
develops unequal pupils. What should the nurse do first?
A. Reassess the client in 30 minutes
B. Notify the healthcare provider immediately
C. Give an oral analgesic
D. Encourage oral fluids
Answer: Notify the healthcare provider immediately.
Rationale: Declining level of consciousness and unequal pupils may indicate
increasing intracranial pressure or brain herniation and require immediate
evaluation.
7. A client with a spinal cord injury develops severe hypertension,
bradycardia, and a pounding headache. Which action should the nurse
take first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Increase IV fluids
Answer: Sit the client upright.
Rationale: These findings suggest autonomic dysreflexia. Sitting the client
upright helps reduce blood pressure while the nurse rapidly identifies and
removes the triggering stimulus.
8. A client with severe asthma suddenly has minimal wheezing and
worsening respiratory distress. How should the nurse interpret this
finding?
A. The asthma attack is improving
B. Airway obstruction may be worsening
, C. Bronchodilator therapy is no longer needed
D. Anxiety is resolving
Answer: Airway obstruction may be worsening.
Rationale: A decrease in wheezing with worsening respiratory distress can
indicate severely reduced airflow and impending respiratory failure.
9. A client with pneumonia has an oxygen saturation of 88% despite
receiving oxygen. Which action should the nurse take first?
A. Increase oxygen according to the prescription/protocol
B. Encourage the client to drink fluids
C. Obtain the client's weight
D. Provide a high-protein meal
Answer: Increase oxygen according to the prescription/protocol.
Rationale: Hypoxemia is an immediate priority. Oxygen therapy should be
optimized according to the prescribed oxygen delivery parameters while
further assessment occurs.
10.A client with chronic obstructive pulmonary disease is receiving oxygen.
Which finding requires immediate attention?
A. Oxygen saturation of 91%
B. Respiratory rate of 20/min
C. Increasing somnolence and confusion
D. Productive cough with clear sputum
Answer: Increasing somnolence and confusion.
Rationale: Altered mental status may indicate worsening hypoxemia or
carbon dioxide retention and can signal respiratory failure.
11.A client with hyperkalemia has peaked T waves on the ECG. Which
medication should the nurse anticipate administering immediately?
A. Calcium gluconate
B. Oral potassium chloride
C. Furosemide only
D. Magnesium sulfate
Exam 1 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A client with acute pulmonary edema is severely dyspneic and has an
oxygen saturation of 82% on room air. Which action should the nurse
take first?
A. Obtain a chest x-ray
B. Place the client in high-Fowler’s position
C. Administer a prescribed diuretic
D. Restrict oral fluids
Answer: Place the client in high-Fowler’s position.
Rationale: Positioning the client upright promotes maximum lung expansion
and decreases venous return to the heart, helping improve oxygenation
rapidly.
2. A client with diabetic ketoacidosis (DKA) has a blood glucose of 620
mg/dL and hypotension. Which prescription should the nurse implement
first?
A. IV regular insulin
B. IV potassium replacement
C. 0.9% sodium chloride infusion
D. Sodium bicarbonate administration
Answer: 0.9% sodium chloride infusion.
,Rationale: Severe dehydration and hypovolemia are major problems in DKA.
Initial treatment generally focuses on restoring circulating volume with
isotonic fluid before or along with insulin therapy.
3. A client with a tension pneumothorax develops severe respiratory
distress, hypotension, and absent breath sounds on one side. Which
intervention is the priority?
A. Obtain a sputum specimen
B. Prepare for emergency needle decompression
C. Encourage coughing and deep breathing
D. Administer oral antibiotics
Answer: Prepare for emergency needle decompression.
Rationale: Tension pneumothorax can rapidly cause cardiovascular collapse.
Immediate decompression is required to relieve pressure and restore
ventilation and circulation.
4. A client with heart failure reports increasing shortness of breath and has
bilateral crackles. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Respiratory rate of 28/min
C. Oxygen saturation of 84%
D. Weight gain of 2 kg in 1 week
Answer: Oxygen saturation of 84%.
Rationale: Severe hypoxemia represents an immediate threat to life and
requires prompt intervention to improve oxygenation.
5. A client with a suspected myocardial infarction reports crushing
substernal chest pain. Which finding is most concerning?
A. Heart rate of 96/min
B. Blood pressure of 108/68 mm Hg
C. New-onset ventricular dysrhythmia
D. Mild nausea
,Answer: New-onset ventricular dysrhythmia.
Rationale: Ventricular dysrhythmias can rapidly deteriorate into ventricular
tachycardia or ventricular fibrillation and are a major complication of acute
myocardial infarction.
6. A client with a traumatic head injury becomes increasingly drowsy and
develops unequal pupils. What should the nurse do first?
A. Reassess the client in 30 minutes
B. Notify the healthcare provider immediately
C. Give an oral analgesic
D. Encourage oral fluids
Answer: Notify the healthcare provider immediately.
Rationale: Declining level of consciousness and unequal pupils may indicate
increasing intracranial pressure or brain herniation and require immediate
evaluation.
7. A client with a spinal cord injury develops severe hypertension,
bradycardia, and a pounding headache. Which action should the nurse
take first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Increase IV fluids
Answer: Sit the client upright.
Rationale: These findings suggest autonomic dysreflexia. Sitting the client
upright helps reduce blood pressure while the nurse rapidly identifies and
removes the triggering stimulus.
8. A client with severe asthma suddenly has minimal wheezing and
worsening respiratory distress. How should the nurse interpret this
finding?
A. The asthma attack is improving
B. Airway obstruction may be worsening
, C. Bronchodilator therapy is no longer needed
D. Anxiety is resolving
Answer: Airway obstruction may be worsening.
Rationale: A decrease in wheezing with worsening respiratory distress can
indicate severely reduced airflow and impending respiratory failure.
9. A client with pneumonia has an oxygen saturation of 88% despite
receiving oxygen. Which action should the nurse take first?
A. Increase oxygen according to the prescription/protocol
B. Encourage the client to drink fluids
C. Obtain the client's weight
D. Provide a high-protein meal
Answer: Increase oxygen according to the prescription/protocol.
Rationale: Hypoxemia is an immediate priority. Oxygen therapy should be
optimized according to the prescribed oxygen delivery parameters while
further assessment occurs.
10.A client with chronic obstructive pulmonary disease is receiving oxygen.
Which finding requires immediate attention?
A. Oxygen saturation of 91%
B. Respiratory rate of 20/min
C. Increasing somnolence and confusion
D. Productive cough with clear sputum
Answer: Increasing somnolence and confusion.
Rationale: Altered mental status may indicate worsening hypoxemia or
carbon dioxide retention and can signal respiratory failure.
11.A client with hyperkalemia has peaked T waves on the ECG. Which
medication should the nurse anticipate administering immediately?
A. Calcium gluconate
B. Oral potassium chloride
C. Furosemide only
D. Magnesium sulfate
