NCLEX RN Physiological Adaptation
Exam 5 100 Questions And Correct
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Rationales 2026 Q&A Instant
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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 prioritize?
A. Administer a prescribed isotonic IV fluid bolus
B. Place the client in a high-Fowler position
C. Restrict oral and IV fluids
D. Administer a prescribed diuretic
Answer: A. Administer a prescribed isotonic IV fluid bolus
Rationale: Rapid isotonic fluid replacement helps restore circulating volume
and tissue perfusion in hypovolemic shock.
2. A client with increased intracranial pressure suddenly develops a widening
pulse pressure, bradycardia, and irregular respirations. How should the nurse
interpret these findings?
A. Neurogenic shock
B. Cushing response
C. Septic shock
D. Spinal shock
Answer: B. Cushing response
,Rationale: The Cushing response consists of hypertension with widened pulse
pressure, bradycardia, and abnormal respirations and indicates increased
intracranial pressure.
3. A client with diabetic ketoacidosis is receiving IV fluids and insulin. Which
finding requires immediate intervention?
A. Blood glucose of 280 mg/dL
B. Potassium of 3.0 mEq/L
C. Respiratory rate of 24/min
D. Urine output of 40 mL/hr
Answer: B. Potassium of 3.0 mEq/L
Rationale: Insulin shifts potassium into cells and can worsen hypokalemia.
Severe hypokalemia increases the risk for life-threatening dysrhythmias and
may require potassium replacement before continuing insulin therapy.
4. A client with acute pulmonary edema is severely dyspneic and coughing
frothy, pink sputum. Which action should the nurse take first?
A. Place the client in high-Fowler position
B. Encourage oral fluids
C. Place the client flat
D. Obtain a routine urine specimen
Answer: A. Place the client in high-Fowler position
Rationale: Upright positioning decreases venous return and improves lung
expansion, helping reduce pulmonary congestion and improve oxygenation.
5. A client with a traumatic brain injury has one pupil that is suddenly dilated
and nonreactive. What is the nurse's priority action?
A. Reassess in 30 minutes
B. Notify the healthcare provider immediately
,C. Dim the lights and allow the client to rest
D. Administer an oral analgesic
Answer: B. Notify the healthcare provider immediately
Rationale: A new unilateral fixed and dilated pupil may indicate brain
herniation or significant intracranial pressure and requires immediate
intervention.
6. A client with acute kidney injury has a potassium level of 6.8 mEq/L and
peaked T waves on the ECG. Which prescribed medication should the nurse
anticipate administering first?
A. Calcium gluconate
B. Oral potassium chloride
C. Spironolactone
D. Magnesium sulfate
Answer: A. Calcium gluconate
Rationale: IV calcium stabilizes the cardiac membrane and reduces the
immediate risk of fatal dysrhythmias in severe hyperkalemia.
7. A client with a chest tube suddenly has continuous bubbling in the water-
seal chamber. What should the nurse do first?
A. Clamp the chest tube
B. Check the tubing and connections for an air leak
C. Remove the chest tube
D. Increase suction pressure
Answer: B. Check the tubing and connections for an air leak
Rationale: Continuous bubbling in the water-seal chamber may indicate an
air leak. The nurse should assess the system and connections before taking
further action.
, 8. A client with a suspected pulmonary embolism suddenly develops severe
dyspnea and chest pain. Which action has the highest priority?
A. Encourage ambulation
B. Apply oxygen
C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: B. Apply oxygen
Rationale: A pulmonary embolism can cause acute hypoxemia. Oxygen
administration is an immediate priority while emergency treatment is
initiated.
9. A client with septic shock has received IV fluids but remains hypotensive.
Which medication does the nurse anticipate?
A. Norepinephrine
B. Furosemide
C. Propranolol
D. Metformin
Answer: A. Norepinephrine
Rationale: Norepinephrine is a commonly used vasopressor for persistent
hypotension in septic shock after adequate fluid resuscitation.
10. A client with Addison disease is admitted with severe weakness,
hypotension, vomiting, and abdominal pain. Which condition should the
nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Myxedema coma
D. Hyperosmolar hyperglycemic state
Answer: B. Addisonian crisis
Exam 5 100 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 prioritize?
A. Administer a prescribed isotonic IV fluid bolus
B. Place the client in a high-Fowler position
C. Restrict oral and IV fluids
D. Administer a prescribed diuretic
Answer: A. Administer a prescribed isotonic IV fluid bolus
Rationale: Rapid isotonic fluid replacement helps restore circulating volume
and tissue perfusion in hypovolemic shock.
2. A client with increased intracranial pressure suddenly develops a widening
pulse pressure, bradycardia, and irregular respirations. How should the nurse
interpret these findings?
A. Neurogenic shock
B. Cushing response
C. Septic shock
D. Spinal shock
Answer: B. Cushing response
,Rationale: The Cushing response consists of hypertension with widened pulse
pressure, bradycardia, and abnormal respirations and indicates increased
intracranial pressure.
3. A client with diabetic ketoacidosis is receiving IV fluids and insulin. Which
finding requires immediate intervention?
A. Blood glucose of 280 mg/dL
B. Potassium of 3.0 mEq/L
C. Respiratory rate of 24/min
D. Urine output of 40 mL/hr
Answer: B. Potassium of 3.0 mEq/L
Rationale: Insulin shifts potassium into cells and can worsen hypokalemia.
Severe hypokalemia increases the risk for life-threatening dysrhythmias and
may require potassium replacement before continuing insulin therapy.
4. A client with acute pulmonary edema is severely dyspneic and coughing
frothy, pink sputum. Which action should the nurse take first?
A. Place the client in high-Fowler position
B. Encourage oral fluids
C. Place the client flat
D. Obtain a routine urine specimen
Answer: A. Place the client in high-Fowler position
Rationale: Upright positioning decreases venous return and improves lung
expansion, helping reduce pulmonary congestion and improve oxygenation.
5. A client with a traumatic brain injury has one pupil that is suddenly dilated
and nonreactive. What is the nurse's priority action?
A. Reassess in 30 minutes
B. Notify the healthcare provider immediately
,C. Dim the lights and allow the client to rest
D. Administer an oral analgesic
Answer: B. Notify the healthcare provider immediately
Rationale: A new unilateral fixed and dilated pupil may indicate brain
herniation or significant intracranial pressure and requires immediate
intervention.
6. A client with acute kidney injury has a potassium level of 6.8 mEq/L and
peaked T waves on the ECG. Which prescribed medication should the nurse
anticipate administering first?
A. Calcium gluconate
B. Oral potassium chloride
C. Spironolactone
D. Magnesium sulfate
Answer: A. Calcium gluconate
Rationale: IV calcium stabilizes the cardiac membrane and reduces the
immediate risk of fatal dysrhythmias in severe hyperkalemia.
7. A client with a chest tube suddenly has continuous bubbling in the water-
seal chamber. What should the nurse do first?
A. Clamp the chest tube
B. Check the tubing and connections for an air leak
C. Remove the chest tube
D. Increase suction pressure
Answer: B. Check the tubing and connections for an air leak
Rationale: Continuous bubbling in the water-seal chamber may indicate an
air leak. The nurse should assess the system and connections before taking
further action.
, 8. A client with a suspected pulmonary embolism suddenly develops severe
dyspnea and chest pain. Which action has the highest priority?
A. Encourage ambulation
B. Apply oxygen
C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: B. Apply oxygen
Rationale: A pulmonary embolism can cause acute hypoxemia. Oxygen
administration is an immediate priority while emergency treatment is
initiated.
9. A client with septic shock has received IV fluids but remains hypotensive.
Which medication does the nurse anticipate?
A. Norepinephrine
B. Furosemide
C. Propranolol
D. Metformin
Answer: A. Norepinephrine
Rationale: Norepinephrine is a commonly used vasopressor for persistent
hypotension in septic shock after adequate fluid resuscitation.
10. A client with Addison disease is admitted with severe weakness,
hypotension, vomiting, and abdominal pain. Which condition should the
nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. Myxedema coma
D. Hyperosmolar hyperglycemic state
Answer: B. Addisonian crisis
