NCLEX RN Physiological Adaptation
Exam 1 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with severe hypovolemia has a blood pressure of 82/48
mm Hg, heart rate of 128/min, and cool, clammy skin. Which
intervention should the nurse implement first?
A. Administer prescribed IV opioid
B. Place the client in high-Fowler position
C. Begin rapid administration of prescribed isotonic IV fluids
D. Restrict oral fluids
Answer: C. Begin rapid administration of prescribed isotonic IV fluids
Rationale: Hypovolemia causes decreased circulating volume and tissue
perfusion. Rapid isotonic fluid replacement is a priority to restore
circulating volume and perfusion.
2. A client with a myocardial infarction suddenly develops severe
dyspnea, crackles, and pink frothy sputum. Which complication
should the nurse suspect?
A. Pulmonary embolism
B. Acute pulmonary edema
C. Pneumothorax
D. Pleural effusion
Answer: B. Acute pulmonary edema
Rationale: Pulmonary edema commonly presents with severe dyspnea,
diffuse crackles, hypoxemia, and pink or frothy sputum.
, 3. A client with diabetic ketoacidosis has a potassium level of 3.0
mEq/L. Which prescription should the nurse question?
A. Cardiac monitoring
B. IV fluids
C. Potassium replacement
D. IV regular insulin infusion immediately
Answer: D. IV regular insulin infusion immediately
Rationale: Insulin drives potassium into cells and can worsen
hypokalemia. Significant hypokalemia should be corrected before insulin
therapy is initiated.
4. A client with a head injury becomes increasingly confused and
develops unequal pupils. What should the nurse do first?
A. Reassess in 30 minutes
B. Give oral fluids
C. Notify the healthcare provider immediately
D. Place the client flat
Answer: C. Notify the healthcare provider immediately
Rationale: New neurologic deterioration and unequal pupils can
indicate increasing intracranial pressure or cerebral herniation and
require immediate intervention.
5. Which finding is most characteristic of hypovolemic shock?
A. Bounding pulse
B. Warm flushed skin
C. Bradycardia
D. Cool, clammy skin
Answer: D. Cool, clammy skin
,Rationale: Peripheral vasoconstriction during hypovolemic shock causes
cool, pale, clammy skin.
6. A client with septic shock has a blood pressure of 78/42 mm Hg
despite fluid resuscitation. Which medication does the nurse
anticipate administering?
A. Furosemide
B. Norepinephrine
C. Metoprolol
D. Digoxin
Answer: B. Norepinephrine
Rationale: Norepinephrine is a first-line vasopressor for persistent
hypotension associated with septic shock after adequate fluid
resuscitation.
7. A client with a spinal cord injury develops hypotension,
bradycardia, and warm, dry skin. Which type of shock is most
likely?
A. Hypovolemic
B. Cardiogenic
C. Septic
D. Neurogenic
Answer: D. Neurogenic
Rationale: Loss of sympathetic tone following spinal cord injury can
cause neurogenic shock characterized by hypotension, bradycardia, and
warm, dry skin.
8. Which assessment finding is most concerning in a client with
increased intracranial pressure?
A. Headache
B. Nausea
, C. Decreasing level of consciousness
D. Photophobia
Answer: C. Decreasing level of consciousness
Rationale: A decreasing level of consciousness is an important early
indicator of worsening neurologic function and increased intracranial
pressure.
9. A client with a traumatic brain injury develops bradycardia,
widened pulse pressure, and irregular respirations. What do these
findings suggest?
A. Hypovolemia
B. Cushing triad
C. Septic shock
D. Spinal shock
Answer: B. Cushing triad
Rationale: Cushing triad consists of hypertension with widened pulse
pressure, bradycardia, and irregular respirations and is associated with
increased intracranial pressure.
10. A client with a chest tube suddenly has continuous bubbling
in the water-seal chamber. What should the nurse suspect?
A. Normal functioning
B. Tube obstruction
C. An air leak
D. Lung re-expansion
Answer: C. An air leak
Rationale: Continuous bubbling in the water-seal chamber usually
indicates an air leak somewhere in the drainage system.
Exam 1 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with severe hypovolemia has a blood pressure of 82/48
mm Hg, heart rate of 128/min, and cool, clammy skin. Which
intervention should the nurse implement first?
A. Administer prescribed IV opioid
B. Place the client in high-Fowler position
C. Begin rapid administration of prescribed isotonic IV fluids
D. Restrict oral fluids
Answer: C. Begin rapid administration of prescribed isotonic IV fluids
Rationale: Hypovolemia causes decreased circulating volume and tissue
perfusion. Rapid isotonic fluid replacement is a priority to restore
circulating volume and perfusion.
2. A client with a myocardial infarction suddenly develops severe
dyspnea, crackles, and pink frothy sputum. Which complication
should the nurse suspect?
A. Pulmonary embolism
B. Acute pulmonary edema
C. Pneumothorax
D. Pleural effusion
Answer: B. Acute pulmonary edema
Rationale: Pulmonary edema commonly presents with severe dyspnea,
diffuse crackles, hypoxemia, and pink or frothy sputum.
, 3. A client with diabetic ketoacidosis has a potassium level of 3.0
mEq/L. Which prescription should the nurse question?
A. Cardiac monitoring
B. IV fluids
C. Potassium replacement
D. IV regular insulin infusion immediately
Answer: D. IV regular insulin infusion immediately
Rationale: Insulin drives potassium into cells and can worsen
hypokalemia. Significant hypokalemia should be corrected before insulin
therapy is initiated.
4. A client with a head injury becomes increasingly confused and
develops unequal pupils. What should the nurse do first?
A. Reassess in 30 minutes
B. Give oral fluids
C. Notify the healthcare provider immediately
D. Place the client flat
Answer: C. Notify the healthcare provider immediately
Rationale: New neurologic deterioration and unequal pupils can
indicate increasing intracranial pressure or cerebral herniation and
require immediate intervention.
5. Which finding is most characteristic of hypovolemic shock?
A. Bounding pulse
B. Warm flushed skin
C. Bradycardia
D. Cool, clammy skin
Answer: D. Cool, clammy skin
,Rationale: Peripheral vasoconstriction during hypovolemic shock causes
cool, pale, clammy skin.
6. A client with septic shock has a blood pressure of 78/42 mm Hg
despite fluid resuscitation. Which medication does the nurse
anticipate administering?
A. Furosemide
B. Norepinephrine
C. Metoprolol
D. Digoxin
Answer: B. Norepinephrine
Rationale: Norepinephrine is a first-line vasopressor for persistent
hypotension associated with septic shock after adequate fluid
resuscitation.
7. A client with a spinal cord injury develops hypotension,
bradycardia, and warm, dry skin. Which type of shock is most
likely?
A. Hypovolemic
B. Cardiogenic
C. Septic
D. Neurogenic
Answer: D. Neurogenic
Rationale: Loss of sympathetic tone following spinal cord injury can
cause neurogenic shock characterized by hypotension, bradycardia, and
warm, dry skin.
8. Which assessment finding is most concerning in a client with
increased intracranial pressure?
A. Headache
B. Nausea
, C. Decreasing level of consciousness
D. Photophobia
Answer: C. Decreasing level of consciousness
Rationale: A decreasing level of consciousness is an important early
indicator of worsening neurologic function and increased intracranial
pressure.
9. A client with a traumatic brain injury develops bradycardia,
widened pulse pressure, and irregular respirations. What do these
findings suggest?
A. Hypovolemia
B. Cushing triad
C. Septic shock
D. Spinal shock
Answer: B. Cushing triad
Rationale: Cushing triad consists of hypertension with widened pulse
pressure, bradycardia, and irregular respirations and is associated with
increased intracranial pressure.
10. A client with a chest tube suddenly has continuous bubbling
in the water-seal chamber. What should the nurse suspect?
A. Normal functioning
B. Tube obstruction
C. An air leak
D. Lung re-expansion
Answer: C. An air leak
Rationale: Continuous bubbling in the water-seal chamber usually
indicates an air leak somewhere in the drainage system.
