NCLEX RN Physiological Adaptation
Exam 5 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client with chronic heart failure is receiving furosemide 40 mg IV twice
daily. The nurse notes a serum potassium level of 3.1 mEq/L. Which
assessment finding is most indicative of this electrolyte imbalance?
A) Flaccid paralysis
B) Hypoactive bowel sounds
C) Muscle weakness and lethargy
D) Peaked T waves on ECG
Answer: C
Rationale: Hypokalemia (normal 3.5–5.0 mEq/L) decreases neuromuscular
excitability, causing muscle weakness, fatigue, lethargy, and hyporeflexia. While
hypoactive bowel sounds may occur due to reduced smooth muscle motility,
generalized muscle weakness and lethargy are the most direct and early
manifestations. Flaccid paralysis is associated with severe hyperkalemia, not
hypokalemia. Peaked T waves on the ECG are a hallmark of hyperkalemia. The
nurse must correlate the low potassium with these clinical signs and promptly
report to prevent life-threatening cardiac dysrhythmias.
2. A client with type 1 diabetes presents with blood glucose 580 mg/dL, serum
pH 7.21, bicarbonate 12 mEq/L, and positive serum ketones. Which
intravenous solution should the nurse anticipate administering first?
A) 0.9% sodium chloride
B) Dextrose 5% in water
C) 0.45% sodium chloride
D) Lactated Ringer's
,Answer: A
Rationale: Diabetic ketoacidosis (DKA) management begins with aggressive fluid
resuscitation using isotonic 0.9% sodium chloride to restore intravascular
volume and improve tissue perfusion. Once blood glucose falls to around 250
mg/dL, dextrose-containing fluids may be added to prevent hypoglycemia while
continuing insulin. Hypotonic solutions like 0.45% NaCl may be used later if
hypernatremia is present, but initial expansion requires isotonic fluid. Lactated
Ringer's contains potassium and could worsen hyperkalemia if renal perfusion is
poor; it is not first-line in DKA. Normal saline is the priority for volume
expansion.
3. A client develops sudden chest pain, tachypnea, and hemoptysis two days
after a total hip replacement. Which condition should the nurse suspect?
A) Fat embolism
B) Myocardial infarction
C) Pulmonary embolism
D) Pneumothorax
Answer: C
Rationale: Classic signs of pulmonary embolism (PE) include sudden dyspnea,
pleuritic chest pain, tachypnea, and hemoptysis. Postoperative orthopedic
patients are at high risk for deep vein thrombosis and subsequent PE due to
venous stasis, endothelial injury, and hypercoagulability (Virchow's triad). Fat
embolism syndrome typically presents with petechiae, confusion, and
respiratory distress 24–72 hours after long bone fracture but hemoptysis is not a
hallmark. Myocardial infarction causes chest pain but not hemoptysis.
Pneumothorax would cause sudden dyspnea and chest pain, but hemoptysis is
unlikely without trauma. Immediate diagnostic workup and anticoagulation are
essential.
4. A nurse is caring for a client with acute kidney injury in the oliguric phase.
Which laboratory value indicates a need for immediate intervention?
A) Blood urea nitrogen 35 mg/dL
B) Serum potassium 6.8 mEq/L
, C) Serum creatinine 2.8 mg/dL
D) Serum sodium 132 mEq/L
Answer: B
Rationale: A serum potassium of 6.8 mEq/L indicates severe hyperkalemia, a life-
threatening complication of oliguric acute kidney injury due to decreased
potassium excretion. This level can cause cardiac arrhythmias, including
ventricular fibrillation and cardiac arrest. The nurse should immediately notify
the healthcare provider and prepare for emergency interventions such as IV
calcium gluconate, insulin and glucose, sodium bicarbonate, or dialysis. Elevated
BUN and creatinine are expected in AKI but are not acutely life-threatening.
Mild hyponatremia (132) is common due to fluid retention and requires
monitoring but is not emergent.
5. A client receiving a blood transfusion develops chills, fever, and low back
pain. Vital signs: temperature 101.2°F (38.4°C), heart rate 110 bpm, blood
pressure 88/52 mmHg. Which type of transfusion reaction does the nurse
suspect?
A) Allergic reaction
B) Febrile nonhemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Answer: C
Rationale: Acute hemolytic transfusion reaction, typically due to ABO
incompatibility, presents with immediate onset of chills, fever, flank or back
pain, hypotension, tachycardia, and hemoglobinuria. The low blood pressure
and back pain are classic signs of red cell destruction and complement
activation, leading to shock and acute renal failure. Allergic reactions usually
manifest with urticaria, pruritus, and wheezing. Febrile nonhemolytic reactions
cause fever and chills but not hypotension and back pain. Circulatory overload
presents with dyspnea, crackles, and hypertension, not hypotension and back
pain. The transfusion must be stopped immediately and the provider notified.
, 6. A client is admitted after a bee sting and develops stridor, wheezing, and
angioedema. Which medication should the nurse administer first?
A) Epinephrine IM
B) Diphenhydramine IV
C) Albuterol nebulizer
D) Methylprednisolone IV
Answer: A
Rationale: Anaphylaxis requires immediate administration of intramuscular
epinephrine into the anterolateral thigh. Epinephrine reverses
bronchoconstriction, vasodilation, and angioedema by alpha- and beta-
adrenergic actions. It is the first-line, life-saving medication. Antihistamines such
as diphenhydramine and corticosteroids such as methylprednisolone are
adjuncts used to prevent biphasic reactions but do not act rapidly enough to
reverse airway compromise. Inhaled albuterol may be given for bronchospasm
after epinephrine if wheezing persists. The priority is to secure the airway and
circulation with epinephrine.
7. A client with liver cirrhosis presents with confusion, asterixis, and elevated
serum ammonia. Which nursing intervention is most important?
A) Administer lactulose as prescribed
B) Restrict dietary protein
C) Maintain bed rest with side rails up
D) Monitor serum bilirubin levels
Answer: A
Rationale: The client is exhibiting signs of hepatic encephalopathy, which results
from the liver's inability to metabolize ammonia and other toxins. Lactulose is
the first-line treatment; it acidifies the colon, trapping ammonia as ammonium
and promoting its excretion via stool. Restricting protein may be necessary if the
client does not tolerate protein, but administration of lactulose is the immediate
intervention to reduce ammonia. Safety measures (side rails) are important due
to confusion but do not treat the underlying cause. Serum bilirubin indicates
Exam 5 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client with chronic heart failure is receiving furosemide 40 mg IV twice
daily. The nurse notes a serum potassium level of 3.1 mEq/L. Which
assessment finding is most indicative of this electrolyte imbalance?
A) Flaccid paralysis
B) Hypoactive bowel sounds
C) Muscle weakness and lethargy
D) Peaked T waves on ECG
Answer: C
Rationale: Hypokalemia (normal 3.5–5.0 mEq/L) decreases neuromuscular
excitability, causing muscle weakness, fatigue, lethargy, and hyporeflexia. While
hypoactive bowel sounds may occur due to reduced smooth muscle motility,
generalized muscle weakness and lethargy are the most direct and early
manifestations. Flaccid paralysis is associated with severe hyperkalemia, not
hypokalemia. Peaked T waves on the ECG are a hallmark of hyperkalemia. The
nurse must correlate the low potassium with these clinical signs and promptly
report to prevent life-threatening cardiac dysrhythmias.
2. A client with type 1 diabetes presents with blood glucose 580 mg/dL, serum
pH 7.21, bicarbonate 12 mEq/L, and positive serum ketones. Which
intravenous solution should the nurse anticipate administering first?
A) 0.9% sodium chloride
B) Dextrose 5% in water
C) 0.45% sodium chloride
D) Lactated Ringer's
,Answer: A
Rationale: Diabetic ketoacidosis (DKA) management begins with aggressive fluid
resuscitation using isotonic 0.9% sodium chloride to restore intravascular
volume and improve tissue perfusion. Once blood glucose falls to around 250
mg/dL, dextrose-containing fluids may be added to prevent hypoglycemia while
continuing insulin. Hypotonic solutions like 0.45% NaCl may be used later if
hypernatremia is present, but initial expansion requires isotonic fluid. Lactated
Ringer's contains potassium and could worsen hyperkalemia if renal perfusion is
poor; it is not first-line in DKA. Normal saline is the priority for volume
expansion.
3. A client develops sudden chest pain, tachypnea, and hemoptysis two days
after a total hip replacement. Which condition should the nurse suspect?
A) Fat embolism
B) Myocardial infarction
C) Pulmonary embolism
D) Pneumothorax
Answer: C
Rationale: Classic signs of pulmonary embolism (PE) include sudden dyspnea,
pleuritic chest pain, tachypnea, and hemoptysis. Postoperative orthopedic
patients are at high risk for deep vein thrombosis and subsequent PE due to
venous stasis, endothelial injury, and hypercoagulability (Virchow's triad). Fat
embolism syndrome typically presents with petechiae, confusion, and
respiratory distress 24–72 hours after long bone fracture but hemoptysis is not a
hallmark. Myocardial infarction causes chest pain but not hemoptysis.
Pneumothorax would cause sudden dyspnea and chest pain, but hemoptysis is
unlikely without trauma. Immediate diagnostic workup and anticoagulation are
essential.
4. A nurse is caring for a client with acute kidney injury in the oliguric phase.
Which laboratory value indicates a need for immediate intervention?
A) Blood urea nitrogen 35 mg/dL
B) Serum potassium 6.8 mEq/L
, C) Serum creatinine 2.8 mg/dL
D) Serum sodium 132 mEq/L
Answer: B
Rationale: A serum potassium of 6.8 mEq/L indicates severe hyperkalemia, a life-
threatening complication of oliguric acute kidney injury due to decreased
potassium excretion. This level can cause cardiac arrhythmias, including
ventricular fibrillation and cardiac arrest. The nurse should immediately notify
the healthcare provider and prepare for emergency interventions such as IV
calcium gluconate, insulin and glucose, sodium bicarbonate, or dialysis. Elevated
BUN and creatinine are expected in AKI but are not acutely life-threatening.
Mild hyponatremia (132) is common due to fluid retention and requires
monitoring but is not emergent.
5. A client receiving a blood transfusion develops chills, fever, and low back
pain. Vital signs: temperature 101.2°F (38.4°C), heart rate 110 bpm, blood
pressure 88/52 mmHg. Which type of transfusion reaction does the nurse
suspect?
A) Allergic reaction
B) Febrile nonhemolytic reaction
C) Acute hemolytic reaction
D) Circulatory overload
Answer: C
Rationale: Acute hemolytic transfusion reaction, typically due to ABO
incompatibility, presents with immediate onset of chills, fever, flank or back
pain, hypotension, tachycardia, and hemoglobinuria. The low blood pressure
and back pain are classic signs of red cell destruction and complement
activation, leading to shock and acute renal failure. Allergic reactions usually
manifest with urticaria, pruritus, and wheezing. Febrile nonhemolytic reactions
cause fever and chills but not hypotension and back pain. Circulatory overload
presents with dyspnea, crackles, and hypertension, not hypotension and back
pain. The transfusion must be stopped immediately and the provider notified.
, 6. A client is admitted after a bee sting and develops stridor, wheezing, and
angioedema. Which medication should the nurse administer first?
A) Epinephrine IM
B) Diphenhydramine IV
C) Albuterol nebulizer
D) Methylprednisolone IV
Answer: A
Rationale: Anaphylaxis requires immediate administration of intramuscular
epinephrine into the anterolateral thigh. Epinephrine reverses
bronchoconstriction, vasodilation, and angioedema by alpha- and beta-
adrenergic actions. It is the first-line, life-saving medication. Antihistamines such
as diphenhydramine and corticosteroids such as methylprednisolone are
adjuncts used to prevent biphasic reactions but do not act rapidly enough to
reverse airway compromise. Inhaled albuterol may be given for bronchospasm
after epinephrine if wheezing persists. The priority is to secure the airway and
circulation with epinephrine.
7. A client with liver cirrhosis presents with confusion, asterixis, and elevated
serum ammonia. Which nursing intervention is most important?
A) Administer lactulose as prescribed
B) Restrict dietary protein
C) Maintain bed rest with side rails up
D) Monitor serum bilirubin levels
Answer: A
Rationale: The client is exhibiting signs of hepatic encephalopathy, which results
from the liver's inability to metabolize ammonia and other toxins. Lactulose is
the first-line treatment; it acidifies the colon, trapping ammonia as ammonium
and promoting its excretion via stool. Restricting protein may be necessary if the
client does not tolerate protein, but administration of lactulose is the immediate
intervention to reduce ammonia. Safety measures (side rails) are important due
to confusion but do not treat the underlying cause. Serum bilirubin indicates
