NCLEX-RN Physiological Adaptation
Exam 4 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. Suction the client every hour
B. Keep the head of the bed at 30 degrees
C. Encourage coughing every 2 hours
D. Place the client in Trendelenburg position
Answer: B. Keep the head of the bed at 30 degrees
Rationale: Elevating the head of the bed to approximately 30 degrees promotes
venous drainage from the brain, helping reduce ICP while maintaining cerebral
perfusion.
2. A client with acute pancreatitis reports severe abdominal pain. Which
laboratory value would the nurse expect to be elevated?
A. Hemoglobin
B. Troponin I
,C. Serum lipase
D. Potassium
Rationale: Serum lipase is the most specific laboratory marker for acute
pancreatitis and remains elevated longer than amylase.
3. A client is admitted with diabetic ketoacidosis (DKA). Which finding requires
immediate intervention?
A. Blood glucose 420 mg/dL
B. Kussmaul respirations
C. Serum potassium 2.9 mEq/L
D. Positive urine ketones
Rationale: Severe hypokalemia increases the risk of life-threatening
dysrhythmias and must be corrected before insulin administration.
4. A nurse is monitoring a client after thyroidectomy. Which assessment
finding suggests hypocalcemia?
A. Bradycardia
B. Hyperactive bowel sounds
C. Positive Chvostek sign
D. Warm flushed skin
Rationale: A positive Chvostek sign indicates neuromuscular irritability caused
by hypocalcemia, often resulting from accidental parathyroid injury.
5. A client develops sudden shortness of breath after a long orthopedic
surgery. Which complication should the nurse suspect?
A. Asthma attack
B. Pneumonia
,C. Pulmonary embolism
D. Pleural effusion
Rationale: Sudden dyspnea following prolonged immobility strongly suggests
pulmonary embolism, which is a medical emergency.
6. A client with chronic kidney disease has peaked T waves on the ECG. Which
electrolyte imbalance is most likely?
A. Hyponatremia
B. Hypocalcemia
C. Hypokalemia
D. Hyperkalemia
Rationale: Peaked T waves are a classic ECG manifestation of hyperkalemia.
7. Which assessment finding is most concerning in a client with liver cirrhosis?
A. Spider angiomas
B. Ascites
C. Confusion and disorientation
D. Jaundice
Rationale: Confusion may indicate hepatic encephalopathy resulting from
elevated ammonia levels requiring immediate treatment.
8. A client receiving blood transfusion develops chills and fever. What is the
nurse's priority action?
A. Administer acetaminophen
B. Slow the transfusion rate
C. Notify the laboratory
D. Stop the transfusion immediately
, Rationale: Stopping the transfusion prevents additional exposure if a transfusion
reaction is occurring.
9. Which symptom is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Hepatomegaly
D. Pulmonary crackles
Rationale: Left-sided heart failure causes pulmonary congestion leading to
crackles and dyspnea.
10.A nurse assesses a client after carotid endarterectomy. Which finding
requires immediate notification of the provider?
A. Mild neck discomfort
B. Hoarse voice
C. Blood pressure 142/80 mmHg
D. Difficulty swallowing with neck swelling
Rationale: Neck swelling may indicate a hematoma compromising the airway
and requires immediate intervention.
11.Which finding indicates improvement in a client with SIADH?
A. Serum sodium returns to 136 mEq/L
B. Urine specific gravity increases
C. Weight increases
D. Urine output decreases
Rationale: Normalization of serum sodium indicates correction of dilutional
hyponatremia.
Exam 4 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. Suction the client every hour
B. Keep the head of the bed at 30 degrees
C. Encourage coughing every 2 hours
D. Place the client in Trendelenburg position
Answer: B. Keep the head of the bed at 30 degrees
Rationale: Elevating the head of the bed to approximately 30 degrees promotes
venous drainage from the brain, helping reduce ICP while maintaining cerebral
perfusion.
2. A client with acute pancreatitis reports severe abdominal pain. Which
laboratory value would the nurse expect to be elevated?
A. Hemoglobin
B. Troponin I
,C. Serum lipase
D. Potassium
Rationale: Serum lipase is the most specific laboratory marker for acute
pancreatitis and remains elevated longer than amylase.
3. A client is admitted with diabetic ketoacidosis (DKA). Which finding requires
immediate intervention?
A. Blood glucose 420 mg/dL
B. Kussmaul respirations
C. Serum potassium 2.9 mEq/L
D. Positive urine ketones
Rationale: Severe hypokalemia increases the risk of life-threatening
dysrhythmias and must be corrected before insulin administration.
4. A nurse is monitoring a client after thyroidectomy. Which assessment
finding suggests hypocalcemia?
A. Bradycardia
B. Hyperactive bowel sounds
C. Positive Chvostek sign
D. Warm flushed skin
Rationale: A positive Chvostek sign indicates neuromuscular irritability caused
by hypocalcemia, often resulting from accidental parathyroid injury.
5. A client develops sudden shortness of breath after a long orthopedic
surgery. Which complication should the nurse suspect?
A. Asthma attack
B. Pneumonia
,C. Pulmonary embolism
D. Pleural effusion
Rationale: Sudden dyspnea following prolonged immobility strongly suggests
pulmonary embolism, which is a medical emergency.
6. A client with chronic kidney disease has peaked T waves on the ECG. Which
electrolyte imbalance is most likely?
A. Hyponatremia
B. Hypocalcemia
C. Hypokalemia
D. Hyperkalemia
Rationale: Peaked T waves are a classic ECG manifestation of hyperkalemia.
7. Which assessment finding is most concerning in a client with liver cirrhosis?
A. Spider angiomas
B. Ascites
C. Confusion and disorientation
D. Jaundice
Rationale: Confusion may indicate hepatic encephalopathy resulting from
elevated ammonia levels requiring immediate treatment.
8. A client receiving blood transfusion develops chills and fever. What is the
nurse's priority action?
A. Administer acetaminophen
B. Slow the transfusion rate
C. Notify the laboratory
D. Stop the transfusion immediately
, Rationale: Stopping the transfusion prevents additional exposure if a transfusion
reaction is occurring.
9. Which symptom is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Hepatomegaly
D. Pulmonary crackles
Rationale: Left-sided heart failure causes pulmonary congestion leading to
crackles and dyspnea.
10.A nurse assesses a client after carotid endarterectomy. Which finding
requires immediate notification of the provider?
A. Mild neck discomfort
B. Hoarse voice
C. Blood pressure 142/80 mmHg
D. Difficulty swallowing with neck swelling
Rationale: Neck swelling may indicate a hematoma compromising the airway
and requires immediate intervention.
11.Which finding indicates improvement in a client with SIADH?
A. Serum sodium returns to 136 mEq/L
B. Urine specific gravity increases
C. Weight increases
D. Urine output decreases
Rationale: Normalization of serum sodium indicates correction of dilutional
hyponatremia.
