NCLEX RN Physiological Adaptation
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. Fluid Volume Deficit Assessment
A client with a 3 day history of vomiting and diarrhea presents with dry
mucous membranes, poor skin turgor, and orthostatic hypotension. Serum
sodium is 148 mEq/L. Which additional finding would the nurse most likely
observe?
A. Bounding peripheral pulses
B. Flat neck veins
C. Moist crackles in the lungs
D. Increased urine output
Answer: B. Flat neck veins
Rationale: In fluid volume deficit, decreased intravascular volume leads to
reduced venous return and flat neck veins when supine. The hypernatremia (148
mEq/L) indicates water loss exceeding sodium loss, consistent with dehydration.
Bounding pulses, crackles, and increased urine output are associated with fluid
volume excess, not deficit. Orthostatic hypotension and poor skin turgor further
support hypovolemia.
2. Hypernatremia Management
A client with diabetes insipidus has a serum sodium of 152 mEq/L. The
nurse is preparing to administer intravenous fluids. Which type of IV
solution would the nurse anticipate?
A. 0.9% sodium chloride
B. 5% dextrose in water
, C. 3% sodium chloride
D. Lactated Ringer's solution
Answer: B. 5% dextrose in water
Rationale: Hypernatremia from water loss requires hypotonic fluids to replace
free water and slowly lower serum sodium. D5W is isotonic in the bag but
becomes hypotonic once dextrose is metabolized, providing free water. Normal
saline and lactated Ringer's are isotonic and would not correct the water deficit
efficiently. Hypertonic saline (3% NaCl) would worsen hypernatremia and is used
for severe hyponatremia. Rapid correction must be avoided to prevent cerebral
edema.
3. Hypokalemia ECG Changes
A client receiving furosemide reports muscle weakness and cramping.
Serum potassium is 2.9 mEq/L. The nurse would monitor the cardiac
monitor for which characteristic finding?
A. Tall peaked T waves
B. Prominent U waves
C. Prolonged PR interval and widened QRS
D. ST segment elevation
Answer: B. Prominent U waves
Rationale: Hypokalemia causes typical ECG changes including flattened T waves,
prominent U waves, ST segment depression, and sometimes premature
ventricular contractions. Peaked T waves and prolonged PR with widened QRS
are hallmarks of hyperkalemia. ST elevation suggests myocardial injury, not
electrolyte imbalance. The client’s muscle symptoms and low potassium place
them at risk for cardiac dysrhythmias related to delayed repolarization seen with
prominent U waves.
4. Hyperkalemia Emergency Management
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L
and ECG shows peaked T waves. The nurse anticipates administering which
medication first?
A. Sodium polystyrene sulfonate (Kayexalate)
, B. Calcium gluconate
C. Regular insulin and 50% dextrose
D. Furosemide 40 mg IV
Answer: B. Calcium gluconate
Rationale: In life-threatening hyperkalemia with ECG changes, calcium gluconate
or calcium chloride is given first to stabilize the cardiac membrane and prevent
fatal dysrhythmias. It does not lower potassium but antagonizes the myocardial
effects. Insulin with dextrose and sodium polystyrene sulfonate help shift or
remove potassium but work more slowly. Calcium must be administered
immediately before other therapies. Furosemide may be used if the client makes
urine but is not the priority when ECG changes are present.
5. Hypocalcemia Clinical Signs
A client post-thyroidectomy develops perioral tingling, muscle cramps, and
a positive Trousseau sign. Serum calcium is 6.9 mg/dL. Which intervention is
the priority?
A. Administer oral calcium carbonate
B. Initiate seizure precautions and prepare IV calcium gluconate
C. Encourage deep breathing and relaxation
D. Place the client in Trendelenburg position
Answer: B. Initiate seizure precautions and prepare IV calcium gluconate
Rationale: Severe hypocalcemia (normal 9–10.5 mg/dL) can cause tetany,
laryngospasm, and seizures. Immediate cardiac monitoring and seizure
precautions are essential. IV calcium gluconate is the treatment of choice for
acute symptomatic hypocalcemia. Oral calcium is appropriate for mild chronic
cases. Trendelenburg does not address the underlying electrolyte crisis, and
deep breathing will not resolve neuromuscular excitability due to low calcium.
6. Hypercalcemia Cancer Related
A client with metastatic breast cancer has a serum calcium of 12.1 mg/dL.
The nurse expects to prioritize which intervention?
A. Encourage weight-bearing exercises
B. Infuse 0.9% sodium chloride intravenously
, C. Restrict oral fluid intake to 1000 mL/day
D. Administer a thiazide diuretic
Answer: B. Infuse 0.9% sodium chloride intravenously
Rationale: Hypercalcemia is treated initially with aggressive IV normal saline to
promote renal excretion of calcium. Once euvolemic, a loop diuretic
(furosemide) may be added, but thiazide diuretics decrease calcium excretion
and worsen hypercalcemia. Weight-bearing exercises are preventive for
osteoporosis, not acute treatment. Fluid restriction concentrates calcium
further. The client needs 3–4 L of saline daily under careful monitoring.
7. Hypomagnesemia Identification
A client with chronic alcoholism is admitted with tremors, hyperactive
reflexes, and torsades de pointes. Which laboratory value does the nurse
anticipate?
A. Magnesium 1.1 mEq/L
B. Magnesium 2.4 mEq/L
C. Magnesium 3.0 mEq/L
D. Magnesium 4.2 mEq/L
Answer: A. Magnesium 1.1 mEq/L
Rationale: Hypomagnesemia (normal 1.5–2.5 mEq/L) often accompanies chronic
alcoholism due to poor intake and renal losses. It manifests with neuromuscular
irritability, seizures, and dangerous ventricular arrhythmias like torsades de
pointes. Elevated magnesium levels cause hyporeflexia, respiratory depression,
and heart block. The presence of tremors, hyperreflexia, and torsades strongly
suggests low magnesium.
8. Metabolic Acidosis Interpretation
Arterial blood gas results: pH 7.31, PaCO₂ 32 mm Hg, HCO₃⁻ 16 mEq/L.
Which condition best explains these findings?
A. Acute respiratory acidosis
B. Metabolic acidosis with partial respiratory compensation
C. Metabolic alkalosis with respiratory compensation
D. Respiratory alkalosis with renal compensation
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. Fluid Volume Deficit Assessment
A client with a 3 day history of vomiting and diarrhea presents with dry
mucous membranes, poor skin turgor, and orthostatic hypotension. Serum
sodium is 148 mEq/L. Which additional finding would the nurse most likely
observe?
A. Bounding peripheral pulses
B. Flat neck veins
C. Moist crackles in the lungs
D. Increased urine output
Answer: B. Flat neck veins
Rationale: In fluid volume deficit, decreased intravascular volume leads to
reduced venous return and flat neck veins when supine. The hypernatremia (148
mEq/L) indicates water loss exceeding sodium loss, consistent with dehydration.
Bounding pulses, crackles, and increased urine output are associated with fluid
volume excess, not deficit. Orthostatic hypotension and poor skin turgor further
support hypovolemia.
2. Hypernatremia Management
A client with diabetes insipidus has a serum sodium of 152 mEq/L. The
nurse is preparing to administer intravenous fluids. Which type of IV
solution would the nurse anticipate?
A. 0.9% sodium chloride
B. 5% dextrose in water
, C. 3% sodium chloride
D. Lactated Ringer's solution
Answer: B. 5% dextrose in water
Rationale: Hypernatremia from water loss requires hypotonic fluids to replace
free water and slowly lower serum sodium. D5W is isotonic in the bag but
becomes hypotonic once dextrose is metabolized, providing free water. Normal
saline and lactated Ringer's are isotonic and would not correct the water deficit
efficiently. Hypertonic saline (3% NaCl) would worsen hypernatremia and is used
for severe hyponatremia. Rapid correction must be avoided to prevent cerebral
edema.
3. Hypokalemia ECG Changes
A client receiving furosemide reports muscle weakness and cramping.
Serum potassium is 2.9 mEq/L. The nurse would monitor the cardiac
monitor for which characteristic finding?
A. Tall peaked T waves
B. Prominent U waves
C. Prolonged PR interval and widened QRS
D. ST segment elevation
Answer: B. Prominent U waves
Rationale: Hypokalemia causes typical ECG changes including flattened T waves,
prominent U waves, ST segment depression, and sometimes premature
ventricular contractions. Peaked T waves and prolonged PR with widened QRS
are hallmarks of hyperkalemia. ST elevation suggests myocardial injury, not
electrolyte imbalance. The client’s muscle symptoms and low potassium place
them at risk for cardiac dysrhythmias related to delayed repolarization seen with
prominent U waves.
4. Hyperkalemia Emergency Management
A client with chronic kidney disease has a serum potassium of 6.8 mEq/L
and ECG shows peaked T waves. The nurse anticipates administering which
medication first?
A. Sodium polystyrene sulfonate (Kayexalate)
, B. Calcium gluconate
C. Regular insulin and 50% dextrose
D. Furosemide 40 mg IV
Answer: B. Calcium gluconate
Rationale: In life-threatening hyperkalemia with ECG changes, calcium gluconate
or calcium chloride is given first to stabilize the cardiac membrane and prevent
fatal dysrhythmias. It does not lower potassium but antagonizes the myocardial
effects. Insulin with dextrose and sodium polystyrene sulfonate help shift or
remove potassium but work more slowly. Calcium must be administered
immediately before other therapies. Furosemide may be used if the client makes
urine but is not the priority when ECG changes are present.
5. Hypocalcemia Clinical Signs
A client post-thyroidectomy develops perioral tingling, muscle cramps, and
a positive Trousseau sign. Serum calcium is 6.9 mg/dL. Which intervention is
the priority?
A. Administer oral calcium carbonate
B. Initiate seizure precautions and prepare IV calcium gluconate
C. Encourage deep breathing and relaxation
D. Place the client in Trendelenburg position
Answer: B. Initiate seizure precautions and prepare IV calcium gluconate
Rationale: Severe hypocalcemia (normal 9–10.5 mg/dL) can cause tetany,
laryngospasm, and seizures. Immediate cardiac monitoring and seizure
precautions are essential. IV calcium gluconate is the treatment of choice for
acute symptomatic hypocalcemia. Oral calcium is appropriate for mild chronic
cases. Trendelenburg does not address the underlying electrolyte crisis, and
deep breathing will not resolve neuromuscular excitability due to low calcium.
6. Hypercalcemia Cancer Related
A client with metastatic breast cancer has a serum calcium of 12.1 mg/dL.
The nurse expects to prioritize which intervention?
A. Encourage weight-bearing exercises
B. Infuse 0.9% sodium chloride intravenously
, C. Restrict oral fluid intake to 1000 mL/day
D. Administer a thiazide diuretic
Answer: B. Infuse 0.9% sodium chloride intravenously
Rationale: Hypercalcemia is treated initially with aggressive IV normal saline to
promote renal excretion of calcium. Once euvolemic, a loop diuretic
(furosemide) may be added, but thiazide diuretics decrease calcium excretion
and worsen hypercalcemia. Weight-bearing exercises are preventive for
osteoporosis, not acute treatment. Fluid restriction concentrates calcium
further. The client needs 3–4 L of saline daily under careful monitoring.
7. Hypomagnesemia Identification
A client with chronic alcoholism is admitted with tremors, hyperactive
reflexes, and torsades de pointes. Which laboratory value does the nurse
anticipate?
A. Magnesium 1.1 mEq/L
B. Magnesium 2.4 mEq/L
C. Magnesium 3.0 mEq/L
D. Magnesium 4.2 mEq/L
Answer: A. Magnesium 1.1 mEq/L
Rationale: Hypomagnesemia (normal 1.5–2.5 mEq/L) often accompanies chronic
alcoholism due to poor intake and renal losses. It manifests with neuromuscular
irritability, seizures, and dangerous ventricular arrhythmias like torsades de
pointes. Elevated magnesium levels cause hyporeflexia, respiratory depression,
and heart block. The presence of tremors, hyperreflexia, and torsades strongly
suggests low magnesium.
8. Metabolic Acidosis Interpretation
Arterial blood gas results: pH 7.31, PaCO₂ 32 mm Hg, HCO₃⁻ 16 mEq/L.
Which condition best explains these findings?
A. Acute respiratory acidosis
B. Metabolic acidosis with partial respiratory compensation
C. Metabolic alkalosis with respiratory compensation
D. Respiratory alkalosis with renal compensation
