NCLEX-RN Physiological Adaptation
Exam 2 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 who suddenly develops dyspnea, chest pain,
and tachycardia after surgery. Which complication should the nurse suspect
first?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Pleural effusion
Answer: Pulmonary embolism
Rationale: A pulmonary embolism commonly presents with sudden dyspnea,
pleuritic chest pain, tachycardia, and hypoxemia following surgery due to
thrombus formation.
2. A client with heart failure develops crackles throughout both lungs. Which
action should the nurse implement first?
,A. Increase oral fluids
B. Place the client in High Fowler's position
C. Encourage coughing exercises
D. Lower the head of the bed
Answer: Place the client in High Fowler's position
Rationale: High Fowler's position improves lung expansion, reduces venous
return, and enhances oxygenation while additional interventions are initiated.
3. Which electrolyte imbalance places a client at greatest risk for ventricular
dysrhythmias?
A. Hypernatremia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypokalemia
Answer: Hypokalemia
Rationale: Low potassium increases myocardial irritability and significantly
increases the risk for life-threatening ventricular dysrhythmias.
4. A client with increased intracranial pressure becomes difficult to arouse.
Which assessment finding requires immediate intervention?
A. Headache
B. Unequal pupils
C. Nausea
D. Restlessness
Answer: Unequal pupils
Rationale: Unequal pupils may indicate brain herniation and require immediate
medical intervention to prevent irreversible neurological damage.
, 5. Which finding indicates that a client is experiencing hypovolemic shock?
A. Bounding pulses
B. Warm flushed skin
C. Hypotension with tachycardia
D. Bradycardia
Answer: Hypotension with tachycardia
Rationale: Hypovolemic shock causes decreased circulating volume, resulting in
hypotension and compensatory tachycardia.
6. A nurse is caring for a client with diabetic ketoacidosis. Which laboratory
result requires immediate attention?
A. Glucose 320 mg/dL
B. Sodium 132 mEq/L
C. Potassium 6.2 mEq/L
D. BUN 26 mg/dL
Answer: Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia can rapidly cause fatal cardiac dysrhythmias
and requires immediate intervention.
7. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Hepatomegaly
D. Pulmonary crackles
Answer: Pulmonary crackles
, Rationale: Left-sided heart failure results in pulmonary congestion, producing
crackles, dyspnea, and orthopnea.
8. Which intervention has the highest priority for a client actively experiencing
a tonic-clonic seizure?
A. Insert an oral airway
B. Restrain the extremities
C. Place a tongue blade in the mouth
D. Protect the client from injury
Answer: Protect the client from injury
Rationale: The priority during a seizure is maintaining safety by protecting the
client from injury without restraining movement.
9. Which client is at greatest risk for acute kidney injury?
A. Client with asthma
B. Client with eczema
C. Client with severe dehydration
D. Client with seasonal allergies
Answer: Client with severe dehydration
Rationale: Severe dehydration reduces renal perfusion, increasing the risk of
acute kidney injury.
10.Which assessment finding suggests worsening respiratory failure?
A. Productive cough
B. Decreasing level of consciousness
C. Mild wheezing
D. Temperature 100°F (37.8°C)
Exam 2 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is caring for a client who suddenly develops dyspnea, chest pain,
and tachycardia after surgery. Which complication should the nurse suspect
first?
A. Atelectasis
B. Pneumonia
C. Pulmonary embolism
D. Pleural effusion
Answer: Pulmonary embolism
Rationale: A pulmonary embolism commonly presents with sudden dyspnea,
pleuritic chest pain, tachycardia, and hypoxemia following surgery due to
thrombus formation.
2. A client with heart failure develops crackles throughout both lungs. Which
action should the nurse implement first?
,A. Increase oral fluids
B. Place the client in High Fowler's position
C. Encourage coughing exercises
D. Lower the head of the bed
Answer: Place the client in High Fowler's position
Rationale: High Fowler's position improves lung expansion, reduces venous
return, and enhances oxygenation while additional interventions are initiated.
3. Which electrolyte imbalance places a client at greatest risk for ventricular
dysrhythmias?
A. Hypernatremia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypokalemia
Answer: Hypokalemia
Rationale: Low potassium increases myocardial irritability and significantly
increases the risk for life-threatening ventricular dysrhythmias.
4. A client with increased intracranial pressure becomes difficult to arouse.
Which assessment finding requires immediate intervention?
A. Headache
B. Unequal pupils
C. Nausea
D. Restlessness
Answer: Unequal pupils
Rationale: Unequal pupils may indicate brain herniation and require immediate
medical intervention to prevent irreversible neurological damage.
, 5. Which finding indicates that a client is experiencing hypovolemic shock?
A. Bounding pulses
B. Warm flushed skin
C. Hypotension with tachycardia
D. Bradycardia
Answer: Hypotension with tachycardia
Rationale: Hypovolemic shock causes decreased circulating volume, resulting in
hypotension and compensatory tachycardia.
6. A nurse is caring for a client with diabetic ketoacidosis. Which laboratory
result requires immediate attention?
A. Glucose 320 mg/dL
B. Sodium 132 mEq/L
C. Potassium 6.2 mEq/L
D. BUN 26 mg/dL
Answer: Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia can rapidly cause fatal cardiac dysrhythmias
and requires immediate intervention.
7. Which assessment finding is most consistent with left-sided heart failure?
A. Peripheral edema
B. Jugular vein distention
C. Hepatomegaly
D. Pulmonary crackles
Answer: Pulmonary crackles
, Rationale: Left-sided heart failure results in pulmonary congestion, producing
crackles, dyspnea, and orthopnea.
8. Which intervention has the highest priority for a client actively experiencing
a tonic-clonic seizure?
A. Insert an oral airway
B. Restrain the extremities
C. Place a tongue blade in the mouth
D. Protect the client from injury
Answer: Protect the client from injury
Rationale: The priority during a seizure is maintaining safety by protecting the
client from injury without restraining movement.
9. Which client is at greatest risk for acute kidney injury?
A. Client with asthma
B. Client with eczema
C. Client with severe dehydration
D. Client with seasonal allergies
Answer: Client with severe dehydration
Rationale: Severe dehydration reduces renal perfusion, increasing the risk of
acute kidney injury.
10.Which assessment finding suggests worsening respiratory failure?
A. Productive cough
B. Decreasing level of consciousness
C. Mild wheezing
D. Temperature 100°F (37.8°C)
