NCLEX RN Physiological Adaptation
Exam 5 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1.
A client with acute pulmonary edema is experiencing severe dyspnea.
Which action should the nurse take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain a daily weight
D. Administer a prescribed stool softener
Answer: B. Place the client in high-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, which can improve oxygenation and reduce
pulmonary congestion.
2.
A client with hypovolemic shock has a blood pressure of 78/42 mm Hg
and a heart rate of 132/min. Which prescription should the nurse
anticipate?
A. Restrict IV fluids
B. Administer rapid isotonic IV fluids
,C. Administer a potassium supplement
D. Place the client on fluid restriction
Answer: B. Administer rapid isotonic IV fluids
Rationale: Hypovolemic shock results from inadequate circulating
volume. Rapid administration of isotonic fluids helps restore
intravascular volume and tissue perfusion.
3.
A client with a suspected tension pneumothorax develops severe
respiratory distress and absent breath sounds on one side. Which
intervention is the priority?
A. Prepare for emergency chest decompression
B. Encourage coughing
C. Administer oral antibiotics
D. Place the client flat
Answer: A. Prepare for emergency chest decompression
Rationale: Tension pneumothorax can rapidly cause cardiovascular
collapse. Immediate decompression is lifesaving.
4.
Which finding is most concerning in a client with increased intracranial
pressure?
A. Mild headache
B. Nausea
C. Decreasing level of consciousness
D. Photophobia
,Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening cerebral dysfunction and increased intracranial
pressure.
5.
A client with diabetic ketoacidosis has a blood glucose of 580 mg/dL.
Which intervention is the priority?
A. Administer IV isotonic fluids
B. Give oral glucose
C. Restrict fluids
D. Administer potassium immediately without assessment
Answer: A. Administer IV isotonic fluids
Rationale: Severe dehydration is common in DKA. Initial treatment
generally focuses on restoring circulating volume with isotonic IV fluids.
6.
A client with hyperkalemia has peaked T waves on the ECG. Which
medication should the nurse anticipate administering first to stabilize
the cardiac membrane?
A. Regular insulin
B. Calcium gluconate
C. Sodium bicarbonate
D. Furosemide
Answer: B. Calcium gluconate
, Rationale: IV calcium stabilizes the myocardial cell membrane and
reduces the immediate risk of life-threatening dysrhythmias.
7.
A client with a spinal cord injury suddenly develops severe
hypertension, headache, and diaphoresis. What should the nurse do
first?
A. Place the client flat
B. Sit the client upright
C. Encourage oral fluids
D. Administer a sedative
Answer: B. Sit the client upright
Rationale: These findings suggest autonomic dysreflexia. Sitting the
client upright helps lower blood pressure while the nurse searches for
and removes the triggering stimulus.
8.
A client with a head injury begins vomiting repeatedly. Which
intervention is most appropriate?
A. Keep the client completely flat
B. Maintain airway protection and monitor neurologic status
C. Encourage ambulation
D. Give large amounts of oral fluid
Answer: B. Maintain airway protection and monitor neurologic status
Rationale: Repeated vomiting increases aspiration risk and may indicate
worsening intracranial pressure.
Exam 5 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1.
A client with acute pulmonary edema is experiencing severe dyspnea.
Which action should the nurse take first?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Obtain a daily weight
D. Administer a prescribed stool softener
Answer: B. Place the client in high-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, which can improve oxygenation and reduce
pulmonary congestion.
2.
A client with hypovolemic shock has a blood pressure of 78/42 mm Hg
and a heart rate of 132/min. Which prescription should the nurse
anticipate?
A. Restrict IV fluids
B. Administer rapid isotonic IV fluids
,C. Administer a potassium supplement
D. Place the client on fluid restriction
Answer: B. Administer rapid isotonic IV fluids
Rationale: Hypovolemic shock results from inadequate circulating
volume. Rapid administration of isotonic fluids helps restore
intravascular volume and tissue perfusion.
3.
A client with a suspected tension pneumothorax develops severe
respiratory distress and absent breath sounds on one side. Which
intervention is the priority?
A. Prepare for emergency chest decompression
B. Encourage coughing
C. Administer oral antibiotics
D. Place the client flat
Answer: A. Prepare for emergency chest decompression
Rationale: Tension pneumothorax can rapidly cause cardiovascular
collapse. Immediate decompression is lifesaving.
4.
Which finding is most concerning in a client with increased intracranial
pressure?
A. Mild headache
B. Nausea
C. Decreasing level of consciousness
D. Photophobia
,Answer: C. Decreasing level of consciousness
Rationale: A declining level of consciousness is an early and important
indicator of worsening cerebral dysfunction and increased intracranial
pressure.
5.
A client with diabetic ketoacidosis has a blood glucose of 580 mg/dL.
Which intervention is the priority?
A. Administer IV isotonic fluids
B. Give oral glucose
C. Restrict fluids
D. Administer potassium immediately without assessment
Answer: A. Administer IV isotonic fluids
Rationale: Severe dehydration is common in DKA. Initial treatment
generally focuses on restoring circulating volume with isotonic IV fluids.
6.
A client with hyperkalemia has peaked T waves on the ECG. Which
medication should the nurse anticipate administering first to stabilize
the cardiac membrane?
A. Regular insulin
B. Calcium gluconate
C. Sodium bicarbonate
D. Furosemide
Answer: B. Calcium gluconate
, Rationale: IV calcium stabilizes the myocardial cell membrane and
reduces the immediate risk of life-threatening dysrhythmias.
7.
A client with a spinal cord injury suddenly develops severe
hypertension, headache, and diaphoresis. What should the nurse do
first?
A. Place the client flat
B. Sit the client upright
C. Encourage oral fluids
D. Administer a sedative
Answer: B. Sit the client upright
Rationale: These findings suggest autonomic dysreflexia. Sitting the
client upright helps lower blood pressure while the nurse searches for
and removes the triggering stimulus.
8.
A client with a head injury begins vomiting repeatedly. Which
intervention is most appropriate?
A. Keep the client completely flat
B. Maintain airway protection and monitor neurologic status
C. Encourage ambulation
D. Give large amounts of oral fluid
Answer: B. Maintain airway protection and monitor neurologic status
Rationale: Repeated vomiting increases aspiration risk and may indicate
worsening intracranial pressure.
