NCLEX-RN Physiological Adaptation
Exam 5 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
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1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which intervention should the nurse implement first?
A. Encourage coughing every 2 hours
B. Elevate the head of the bed to 30 degrees
C. Place the client flat in bed
D. Flex the client's neck
Answer: B. Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed promotes venous drainage from the
brain, reducing intracranial pressure. Neck flexion and lying flat impede venous
return, while coughing temporarily increases ICP.
2. A client with diabetic ketoacidosis (DKA) has a serum potassium of 5.8
mEq/L before insulin therapy. What should the nurse anticipate after insulin
administration?
,A. Potassium will remain elevated.
B. Potassium will increase significantly.
C. Potassium will move into cells, lowering serum levels.
D. Potassium will not change.
Answer: C. Potassium will move into cells, lowering serum levels.
Rationale: Insulin drives potassium into cells, decreasing serum potassium levels.
Careful monitoring is essential because hypokalemia may develop rapidly.
3. Which assessment finding indicates improvement in a client receiving
treatment for pulmonary edema?
A. Crackles throughout both lungs
B. Pink frothy sputum
C. Oxygen saturation of 84%
D. Clearer breath sounds and improved oxygen saturation
Answer: D. Clearer breath sounds and improved oxygen saturation
Rationale: Resolution of pulmonary edema is reflected by improved oxygenation
and decreasing crackles as fluid leaves the alveoli.
4. A nurse is caring for a client experiencing hypovolemic shock. Which finding
indicates improved tissue perfusion?
A. Blood pressure 82/48 mm Hg
B. Urine output 10 mL/hr
C. Urine output 35 mL/hr
D. Cool, clammy skin
Answer: C. Urine output 35 mL/hr
Rationale: Urine output of at least 30 mL/hr suggests adequate renal perfusion
and improved circulation.
, 5. Which electrolyte imbalance places a client at greatest risk for ventricular
dysrhythmias?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Low potassium increases myocardial irritability, significantly
increasing the risk of life-threatening ventricular dysrhythmias.
6. A client with syndrome of inappropriate antidiuretic hormone secretion
(SIADH) is at highest risk for which complication?
A. Hypercalcemia
B. Seizures
C. Hyperglycemia
D. Polyuria
Answer: B. Seizures
Rationale: Severe hyponatremia from SIADH can cause cerebral edema and
seizures due to water movement into brain cells.
7. Which finding requires immediate intervention in a client receiving a blood
transfusion?
A. Temperature increase of 0.5°F
B. Mild anxiety
C. Low back pain and chills
D. Heart rate of 88 beats/min
, Answer: C. Low back pain and chills
Rationale: Low back pain and chills are classic signs of an acute hemolytic
transfusion reaction requiring immediate discontinuation of the transfusion.
8. A client develops sudden shortness of breath after central venous catheter
removal. Which complication should the nurse suspect?
A. Pulmonary edema
B. Pneumonia
C. Air embolism
D. Atelectasis
Answer: C. Air embolism
Rationale: Air entering the venous circulation during catheter removal can
obstruct pulmonary blood flow and cause acute respiratory distress.
9. A client with acute kidney injury should be monitored most closely for
which laboratory value?
A. Hemoglobin
B. Platelets
C. Potassium
D. Cholesterol
Answer: C. Potassium
Rationale: Impaired renal excretion frequently causes hyperkalemia, which may
result in fatal cardiac dysrhythmias.
10.A nurse is caring for a client with bacterial meningitis. Which intervention
has the highest priority?
Exam 5 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which intervention should the nurse implement first?
A. Encourage coughing every 2 hours
B. Elevate the head of the bed to 30 degrees
C. Place the client flat in bed
D. Flex the client's neck
Answer: B. Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed promotes venous drainage from the
brain, reducing intracranial pressure. Neck flexion and lying flat impede venous
return, while coughing temporarily increases ICP.
2. A client with diabetic ketoacidosis (DKA) has a serum potassium of 5.8
mEq/L before insulin therapy. What should the nurse anticipate after insulin
administration?
,A. Potassium will remain elevated.
B. Potassium will increase significantly.
C. Potassium will move into cells, lowering serum levels.
D. Potassium will not change.
Answer: C. Potassium will move into cells, lowering serum levels.
Rationale: Insulin drives potassium into cells, decreasing serum potassium levels.
Careful monitoring is essential because hypokalemia may develop rapidly.
3. Which assessment finding indicates improvement in a client receiving
treatment for pulmonary edema?
A. Crackles throughout both lungs
B. Pink frothy sputum
C. Oxygen saturation of 84%
D. Clearer breath sounds and improved oxygen saturation
Answer: D. Clearer breath sounds and improved oxygen saturation
Rationale: Resolution of pulmonary edema is reflected by improved oxygenation
and decreasing crackles as fluid leaves the alveoli.
4. A nurse is caring for a client experiencing hypovolemic shock. Which finding
indicates improved tissue perfusion?
A. Blood pressure 82/48 mm Hg
B. Urine output 10 mL/hr
C. Urine output 35 mL/hr
D. Cool, clammy skin
Answer: C. Urine output 35 mL/hr
Rationale: Urine output of at least 30 mL/hr suggests adequate renal perfusion
and improved circulation.
, 5. Which electrolyte imbalance places a client at greatest risk for ventricular
dysrhythmias?
A. Hypernatremia
B. Hypocalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: C. Hypokalemia
Rationale: Low potassium increases myocardial irritability, significantly
increasing the risk of life-threatening ventricular dysrhythmias.
6. A client with syndrome of inappropriate antidiuretic hormone secretion
(SIADH) is at highest risk for which complication?
A. Hypercalcemia
B. Seizures
C. Hyperglycemia
D. Polyuria
Answer: B. Seizures
Rationale: Severe hyponatremia from SIADH can cause cerebral edema and
seizures due to water movement into brain cells.
7. Which finding requires immediate intervention in a client receiving a blood
transfusion?
A. Temperature increase of 0.5°F
B. Mild anxiety
C. Low back pain and chills
D. Heart rate of 88 beats/min
, Answer: C. Low back pain and chills
Rationale: Low back pain and chills are classic signs of an acute hemolytic
transfusion reaction requiring immediate discontinuation of the transfusion.
8. A client develops sudden shortness of breath after central venous catheter
removal. Which complication should the nurse suspect?
A. Pulmonary edema
B. Pneumonia
C. Air embolism
D. Atelectasis
Answer: C. Air embolism
Rationale: Air entering the venous circulation during catheter removal can
obstruct pulmonary blood flow and cause acute respiratory distress.
9. A client with acute kidney injury should be monitored most closely for
which laboratory value?
A. Hemoglobin
B. Platelets
C. Potassium
D. Cholesterol
Answer: C. Potassium
Rationale: Impaired renal excretion frequently causes hyperkalemia, which may
result in fatal cardiac dysrhythmias.
10.A nurse is caring for a client with bacterial meningitis. Which intervention
has the highest priority?
