NCLEX-RN Physiological Adaptation
Exam 1 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
Pdf
1. A nurse is caring for a client with increased intracranial pressure (ICP).
Which assessment finding requires immediate intervention?
A. Headache rated 4/10
B. Decreased level of consciousness
C. Temperature of 99.5°F (37.5°C)
D. Heart rate of 88 beats/min
Answer: B. Decreased level of consciousness
Rationale: A declining level of consciousness is often the earliest and most
significant sign of worsening intracranial pressure and requires immediate
intervention to prevent permanent neurological injury.
2. A client with heart failure develops sudden shortness of breath and pink
frothy sputum. What is the nurse's priority action?
A. Encourage oral fluids
B. Place the client flat in bed
,C. Position the client in high Fowler's position
D. Offer a high-protein snack
Answer: C. Position the client in high Fowler's position
Rationale: High Fowler's position decreases venous return, improves lung
expansion, and enhances oxygenation during acute pulmonary edema.
3. Which laboratory result is most concerning in a client receiving
chemotherapy?
A. Hemoglobin 13 g/dL
B. Platelets 180,000/mm³
C. Sodium 138 mEq/L
D. Absolute neutrophil count (ANC) 400/mm³
Answer: D. Absolute neutrophil count (ANC) 400/mm³
Rationale: An ANC below 500/mm³ places the client at extremely high risk for
infection and requires protective precautions.
4. A nurse suspects hypovolemic shock in a client after surgery. Which finding
supports this diagnosis?
A. Bradycardia
B. Bounding pulses
C. Cool, clammy skin
D. Hypertension
Answer: C. Cool, clammy skin
Rationale: Cool, clammy skin results from peripheral vasoconstriction as the
body attempts to maintain perfusion during hypovolemic shock.
5. A client develops stridor after thyroid surgery. What is the nurse's priority?
,A. Encourage coughing
B. Administer oral fluids
C. Reposition to prone
D. Prepare for emergency airway management
Answer: D. Prepare for emergency airway management
Rationale: Stridor indicates airway obstruction, which is a life-threatening
emergency requiring immediate intervention.
6. Which client is at greatest risk for aspiration?
A. Client with hypertension
B. Client with a recent stroke and dysphagia
C. Client with osteoarthritis
D. Client with cataracts
Answer: B. Client with a recent stroke and dysphagia
Rationale: Dysphagia significantly increases the risk of aspiration due to
impaired swallowing mechanisms.
7. Which electrolyte imbalance is commonly associated with severe vomiting?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypercalcemia
Answer: C. Hypokalemia
Rationale: Vomiting causes potassium loss, placing clients at risk for
hypokalemia and cardiac dysrhythmias.
8. Which finding suggests worsening respiratory distress?
, A. Respiratory rate 18/min
B. Oxygen saturation 97%
C. Use of accessory muscles
D. Clear lung sounds
Answer: C. Use of accessory muscles
Rationale: Accessory muscle use indicates increased work of breathing and
worsening respiratory compromise.
9. A client has a blood glucose of 42 mg/dL and is unconscious. Which
intervention is appropriate?
A. Give orange juice
B. Administer insulin
C. Encourage food intake
D. Administer intravenous dextrose
Answer: D. Administer intravenous dextrose
Rationale: An unconscious client cannot safely swallow. Intravenous dextrose
rapidly corrects severe hypoglycemia.
10.Which assessment finding indicates possible cardiac tamponade?
A. Hypertension
B. Bradycardia
C. Jugular venous distention
D. Bounding pulses
Answer: C. Jugular venous distention
Rationale: Jugular venous distention is part of Beck's triad associated with
cardiac tamponade.
Exam 1 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 assessment finding requires immediate intervention?
A. Headache rated 4/10
B. Decreased level of consciousness
C. Temperature of 99.5°F (37.5°C)
D. Heart rate of 88 beats/min
Answer: B. Decreased level of consciousness
Rationale: A declining level of consciousness is often the earliest and most
significant sign of worsening intracranial pressure and requires immediate
intervention to prevent permanent neurological injury.
2. A client with heart failure develops sudden shortness of breath and pink
frothy sputum. What is the nurse's priority action?
A. Encourage oral fluids
B. Place the client flat in bed
,C. Position the client in high Fowler's position
D. Offer a high-protein snack
Answer: C. Position the client in high Fowler's position
Rationale: High Fowler's position decreases venous return, improves lung
expansion, and enhances oxygenation during acute pulmonary edema.
3. Which laboratory result is most concerning in a client receiving
chemotherapy?
A. Hemoglobin 13 g/dL
B. Platelets 180,000/mm³
C. Sodium 138 mEq/L
D. Absolute neutrophil count (ANC) 400/mm³
Answer: D. Absolute neutrophil count (ANC) 400/mm³
Rationale: An ANC below 500/mm³ places the client at extremely high risk for
infection and requires protective precautions.
4. A nurse suspects hypovolemic shock in a client after surgery. Which finding
supports this diagnosis?
A. Bradycardia
B. Bounding pulses
C. Cool, clammy skin
D. Hypertension
Answer: C. Cool, clammy skin
Rationale: Cool, clammy skin results from peripheral vasoconstriction as the
body attempts to maintain perfusion during hypovolemic shock.
5. A client develops stridor after thyroid surgery. What is the nurse's priority?
,A. Encourage coughing
B. Administer oral fluids
C. Reposition to prone
D. Prepare for emergency airway management
Answer: D. Prepare for emergency airway management
Rationale: Stridor indicates airway obstruction, which is a life-threatening
emergency requiring immediate intervention.
6. Which client is at greatest risk for aspiration?
A. Client with hypertension
B. Client with a recent stroke and dysphagia
C. Client with osteoarthritis
D. Client with cataracts
Answer: B. Client with a recent stroke and dysphagia
Rationale: Dysphagia significantly increases the risk of aspiration due to
impaired swallowing mechanisms.
7. Which electrolyte imbalance is commonly associated with severe vomiting?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hypercalcemia
Answer: C. Hypokalemia
Rationale: Vomiting causes potassium loss, placing clients at risk for
hypokalemia and cardiac dysrhythmias.
8. Which finding suggests worsening respiratory distress?
, A. Respiratory rate 18/min
B. Oxygen saturation 97%
C. Use of accessory muscles
D. Clear lung sounds
Answer: C. Use of accessory muscles
Rationale: Accessory muscle use indicates increased work of breathing and
worsening respiratory compromise.
9. A client has a blood glucose of 42 mg/dL and is unconscious. Which
intervention is appropriate?
A. Give orange juice
B. Administer insulin
C. Encourage food intake
D. Administer intravenous dextrose
Answer: D. Administer intravenous dextrose
Rationale: An unconscious client cannot safely swallow. Intravenous dextrose
rapidly corrects severe hypoglycemia.
10.Which assessment finding indicates possible cardiac tamponade?
A. Hypertension
B. Bradycardia
C. Jugular venous distention
D. Bounding pulses
Answer: C. Jugular venous distention
Rationale: Jugular venous distention is part of Beck's triad associated with
cardiac tamponade.
