NCLEX-RN Physiological Adaptation 4 Exam
(2025/2026) – Verified Questions & Answers
for Mastery-Level Pathophysiology,
System-Wide Clinical Management, and
NCLEX®-RN® Superiority
1. A patient with DKA has Kussmaul respirations and a blood glucose of 520 mg/dL. Which
arterial blood gas pattern is most likely?
A. pH 7.55, PaCO₂ 28 mmHg, HCO₃⁻ 24 mEq/L
B. pH 7.20, PaCO₂ 30 mmHg, HCO₃⁻ 12 mEq/L
C. pH 7.45, PaCO₂ 40 mmHg, HCO₃⁻ 24 mEq/L
D. pH 7.60, PaCO₂ 20 mmHg, HCO₃⁻ 10 mEq/L
Answer: B.
Rationale: DKA causes metabolic acidosis (low pH, low HCO₃⁻) with respiratory
compensation (low PaCO₂ via hyperventilation).
2. A patient in septic shock has warm, flushed skin and a wide pulse pressure. The primary
hemodynamic finding is:
A. Decreased systemic vascular resistance (SVR)
B. Increased SVR
C. Decreased cardiac output
D. Elevated pulmonary capillary wedge pressure
Answer: A.
Rationale: Early septic shock often presents with vasodilation and decreased SVR with
normal/increased cardiac output.
3. A burned patient (partial-thickness, 40% TBSA) is 6 hours post-injury. Which fluid is
appropriate for resuscitation in first 24 hours?
A. 0.9% NS only
B. Lactated Ringer’s, calculated by Parkland formula
C. 5% dextrose in water
D. Albumin bolus immediately
Answer: B.
Rationale: Parkland formula uses LR for burn resuscitation (4 mL × body weight kg ×
, %TBSA) in first 24 hrs.
4. A patient with acute pulmonary edema from left ventricular failure is breathless, has
crackles, and pink frothy sputum. Priority medication:
A. IV furosemide and morphine, upright position, O₂
B. Oral metoprolol immediately
C. Subcutaneous insulin
D. IV normal saline bolus
Answer: A.
Rationale: Loop diuretic reduces preload; morphine can reduce anxiety and preload;
oxygen and high Fowler’s help.
5. A young adult with bacterial meningitis shows nuchal rigidity and photophobia. Best
immediate action:
A. Start empiric IV antibiotics after blood cultures
B. Wait for CT scan before antibiotics
C. Give oral acetaminophen and discharge
D. Start steroids only
Answer: A.
Rationale: Empiric IV antibiotics should be started promptly after blood cultures; do not
delay for imaging if meningitis suspected.
6. A patient on heparin develops sudden thrombocytopenia on day 7 and new thrombosis.
The likely diagnosis:
A. Heparin-induced thrombocytopenia (HIT)
B. ITP
C. DIC
D. Thrombocytopenia from sepsis
Answer: A.
Rationale: HIT typically occurs 5–10 days after exposure, with platelet drop and
paradoxical thrombosis.
7. A patient with COPD has chronic CO₂ retention. Which oxygen prescription is safest?
A. High-flow O₂ (10–12 L/min) by nonrebreather
B. Titrate O₂ to SpO₂ 88–92%
C. Room air only regardless of saturation
D. 100% O₂ by NC at 6 L/min continuously
Answer: B.
Rationale: In COPD with CO₂ retention, targeting 88–92% prevents suppressing hypoxic
drive and avoids hypercapnia.
8. A patient with acute pancreatitis develops hypocalcemia (perioral numbness, Chvostek
sign). Mechanism:
A. Fat necrosis binds calcium, lowering serum Ca²⁺
, B. Increased PTH secretion
C. Renal failure exclusively
D. Excess calcium excretion due to diuretics
Answer: A.
Rationale: In pancreatitis, saponification binds calcium to fatty acids, decreasing serum
calcium.
9. Which ECG change is earliest in hyperkalemia?
A. Peaked T waves
B. Prolonged QT interval
C. ST elevation
D. U waves
Answer: A.
Rationale: Peaked (tall, narrow) T waves are the earliest ECG sign of hyperkalemia.
10.A patient with suspected acute mesenteric ischemia complains of severe abdominal pain
out of proportion to exam. Best next test:
A. CT angiography of abdomen
B. Abdominal x-ray
C. Colonoscopy
D. HIDA scan
Answer: A.
Rationale: CT angiography is sensitive and helps detect mesenteric vessel occlusion.
11.A postoperative patient develops sudden chest pain and dyspnea; oxygen saturation
drops. Suspected pulmonary embolism. Initial best intervention:
A. Apply oxygen, obtain CT pulmonary angiography if stable
B. Immediate thrombolysis without imaging for all cases
C. Start broad-spectrum antibiotics
D. Observe and give analgesics only
Answer: A.
Rationale: Start oxygen and stabilize; confirm with CT angiography if patient can
tolerate; some unstable patients need immediate treatment.
12.A patient with acute adrenal insufficiency has hypotension, hyponatremia, and
hyperkalemia. Best immediate treatment:
A. IV hydrocortisone and IV fluids with D5NS
B. Oral fludrocortisone only
C. Rapid infusion of isotonic saline without steroids
D. IV insulin and dextrose
Answer: A.
Rationale: IV glucocorticoids and fluids correct hypotension and electrolyte
abnormalities; fludrocortisone for later if needed.
, 13.A patient with myasthenia gravis has escalating respiratory weakness. Tensilon
(edrophonium) test improves strength briefly. Interpretation and priority:
A. Myasthenic crisis — give AChE inhibitors and consider intubation/plasmapheresis
B. Cholinergic crisis — stop AChE inhibitors immediately
C. Not useful — observe only
D. Indicates Guillain-Barré syndrome
Answer: A.
Rationale: Improvement after edrophonium suggests myasthenic crisis; monitor airway
and treat with anticholinesterase, immunotherapy, or IVIG/plasmapheresis.
14.In acute ischemic stroke, the patient arrives within 90 minutes of onset and CT excludes
hemorrhage. Next priority:
A. Consider IV tPA if no contraindications
B. Start aspirin immediately and never tPA
C. Perform lumbar puncture
D. Give heparin bolus
Answer: A.
Rationale: IV alteplase within the therapeutic window (often up to 4.5 hrs) is indicated if
criteria met.
15.A patient with CHF has elevated BNP. BNP correlates best with:
A. Ventricular wall stress / volume overload
B. Degree of infection
C. Liver failure severity
D. Renal filtration rate only
Answer: A.
Rationale: BNP is released from ventricular myocytes in response to increased wall
stress from volume/pressure overload.
16.A patient with suspected acute coronary syndrome has ST-segment elevation in V2–V4.
This indicates infarction in which area?
A. Anterior wall (LAD territory)
B. Inferior wall (RCA)
C. Lateral wall (LCx)
D. Posterior wall
Answer: A.
Rationale: ST elevation in V2–V4 indicates anterior wall (left anterior descending artery)
MI.
17.A patient receiving aminoglycosides reports decreased hearing and balance. Which
toxicity is likely?
A. Ototoxicity (vestibular/cochlear)
B. Nephrotoxicity only
C. Hepatotoxicity
(2025/2026) – Verified Questions & Answers
for Mastery-Level Pathophysiology,
System-Wide Clinical Management, and
NCLEX®-RN® Superiority
1. A patient with DKA has Kussmaul respirations and a blood glucose of 520 mg/dL. Which
arterial blood gas pattern is most likely?
A. pH 7.55, PaCO₂ 28 mmHg, HCO₃⁻ 24 mEq/L
B. pH 7.20, PaCO₂ 30 mmHg, HCO₃⁻ 12 mEq/L
C. pH 7.45, PaCO₂ 40 mmHg, HCO₃⁻ 24 mEq/L
D. pH 7.60, PaCO₂ 20 mmHg, HCO₃⁻ 10 mEq/L
Answer: B.
Rationale: DKA causes metabolic acidosis (low pH, low HCO₃⁻) with respiratory
compensation (low PaCO₂ via hyperventilation).
2. A patient in septic shock has warm, flushed skin and a wide pulse pressure. The primary
hemodynamic finding is:
A. Decreased systemic vascular resistance (SVR)
B. Increased SVR
C. Decreased cardiac output
D. Elevated pulmonary capillary wedge pressure
Answer: A.
Rationale: Early septic shock often presents with vasodilation and decreased SVR with
normal/increased cardiac output.
3. A burned patient (partial-thickness, 40% TBSA) is 6 hours post-injury. Which fluid is
appropriate for resuscitation in first 24 hours?
A. 0.9% NS only
B. Lactated Ringer’s, calculated by Parkland formula
C. 5% dextrose in water
D. Albumin bolus immediately
Answer: B.
Rationale: Parkland formula uses LR for burn resuscitation (4 mL × body weight kg ×
, %TBSA) in first 24 hrs.
4. A patient with acute pulmonary edema from left ventricular failure is breathless, has
crackles, and pink frothy sputum. Priority medication:
A. IV furosemide and morphine, upright position, O₂
B. Oral metoprolol immediately
C. Subcutaneous insulin
D. IV normal saline bolus
Answer: A.
Rationale: Loop diuretic reduces preload; morphine can reduce anxiety and preload;
oxygen and high Fowler’s help.
5. A young adult with bacterial meningitis shows nuchal rigidity and photophobia. Best
immediate action:
A. Start empiric IV antibiotics after blood cultures
B. Wait for CT scan before antibiotics
C. Give oral acetaminophen and discharge
D. Start steroids only
Answer: A.
Rationale: Empiric IV antibiotics should be started promptly after blood cultures; do not
delay for imaging if meningitis suspected.
6. A patient on heparin develops sudden thrombocytopenia on day 7 and new thrombosis.
The likely diagnosis:
A. Heparin-induced thrombocytopenia (HIT)
B. ITP
C. DIC
D. Thrombocytopenia from sepsis
Answer: A.
Rationale: HIT typically occurs 5–10 days after exposure, with platelet drop and
paradoxical thrombosis.
7. A patient with COPD has chronic CO₂ retention. Which oxygen prescription is safest?
A. High-flow O₂ (10–12 L/min) by nonrebreather
B. Titrate O₂ to SpO₂ 88–92%
C. Room air only regardless of saturation
D. 100% O₂ by NC at 6 L/min continuously
Answer: B.
Rationale: In COPD with CO₂ retention, targeting 88–92% prevents suppressing hypoxic
drive and avoids hypercapnia.
8. A patient with acute pancreatitis develops hypocalcemia (perioral numbness, Chvostek
sign). Mechanism:
A. Fat necrosis binds calcium, lowering serum Ca²⁺
, B. Increased PTH secretion
C. Renal failure exclusively
D. Excess calcium excretion due to diuretics
Answer: A.
Rationale: In pancreatitis, saponification binds calcium to fatty acids, decreasing serum
calcium.
9. Which ECG change is earliest in hyperkalemia?
A. Peaked T waves
B. Prolonged QT interval
C. ST elevation
D. U waves
Answer: A.
Rationale: Peaked (tall, narrow) T waves are the earliest ECG sign of hyperkalemia.
10.A patient with suspected acute mesenteric ischemia complains of severe abdominal pain
out of proportion to exam. Best next test:
A. CT angiography of abdomen
B. Abdominal x-ray
C. Colonoscopy
D. HIDA scan
Answer: A.
Rationale: CT angiography is sensitive and helps detect mesenteric vessel occlusion.
11.A postoperative patient develops sudden chest pain and dyspnea; oxygen saturation
drops. Suspected pulmonary embolism. Initial best intervention:
A. Apply oxygen, obtain CT pulmonary angiography if stable
B. Immediate thrombolysis without imaging for all cases
C. Start broad-spectrum antibiotics
D. Observe and give analgesics only
Answer: A.
Rationale: Start oxygen and stabilize; confirm with CT angiography if patient can
tolerate; some unstable patients need immediate treatment.
12.A patient with acute adrenal insufficiency has hypotension, hyponatremia, and
hyperkalemia. Best immediate treatment:
A. IV hydrocortisone and IV fluids with D5NS
B. Oral fludrocortisone only
C. Rapid infusion of isotonic saline without steroids
D. IV insulin and dextrose
Answer: A.
Rationale: IV glucocorticoids and fluids correct hypotension and electrolyte
abnormalities; fludrocortisone for later if needed.
, 13.A patient with myasthenia gravis has escalating respiratory weakness. Tensilon
(edrophonium) test improves strength briefly. Interpretation and priority:
A. Myasthenic crisis — give AChE inhibitors and consider intubation/plasmapheresis
B. Cholinergic crisis — stop AChE inhibitors immediately
C. Not useful — observe only
D. Indicates Guillain-Barré syndrome
Answer: A.
Rationale: Improvement after edrophonium suggests myasthenic crisis; monitor airway
and treat with anticholinesterase, immunotherapy, or IVIG/plasmapheresis.
14.In acute ischemic stroke, the patient arrives within 90 minutes of onset and CT excludes
hemorrhage. Next priority:
A. Consider IV tPA if no contraindications
B. Start aspirin immediately and never tPA
C. Perform lumbar puncture
D. Give heparin bolus
Answer: A.
Rationale: IV alteplase within the therapeutic window (often up to 4.5 hrs) is indicated if
criteria met.
15.A patient with CHF has elevated BNP. BNP correlates best with:
A. Ventricular wall stress / volume overload
B. Degree of infection
C. Liver failure severity
D. Renal filtration rate only
Answer: A.
Rationale: BNP is released from ventricular myocytes in response to increased wall
stress from volume/pressure overload.
16.A patient with suspected acute coronary syndrome has ST-segment elevation in V2–V4.
This indicates infarction in which area?
A. Anterior wall (LAD territory)
B. Inferior wall (RCA)
C. Lateral wall (LCx)
D. Posterior wall
Answer: A.
Rationale: ST elevation in V2–V4 indicates anterior wall (left anterior descending artery)
MI.
17.A patient receiving aminoglycosides reports decreased hearing and balance. Which
toxicity is likely?
A. Ototoxicity (vestibular/cochlear)
B. Nephrotoxicity only
C. Hepatotoxicity
