NCLEX RN Physiological Adaptation
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with acute pulmonary edema is severely dyspneic and has an
oxygen saturation of 82%. Which action should the nurse take first?
A. Obtain a chest x-ray
B. Place the client in high-Fowler's position
C. Administer a prescribed diuretic
D. Restrict oral fluids
Answer: B. Place the client in high-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, helping improve oxygenation rapidly.
2. A client with diabetic ketoacidosis has a potassium level of 2.8
mEq/L. Which prescription should the nurse question?
A. IV regular insulin
B. Cardiac monitoring
C. IV potassium replacement
D. 0.9% sodium chloride infusion
Answer: A. IV regular insulin
Rationale: Insulin drives potassium into cells and can worsen severe
hypokalemia. Potassium should be corrected before insulin is
administered when the serum potassium is critically low.
3. A client develops sudden facial drooping, slurred speech, and
weakness of the right arm. What is the nurse's priority action?
,A. Give aspirin immediately
B. Determine the time symptoms began
C. Place the client in Trendelenburg position
D. Administer oral fluids
Answer: B. Determine the time symptoms began
Rationale: The onset time is critical in determining eligibility for time-
sensitive stroke therapies.
4. A client with increased intracranial pressure is being monitored.
Which finding requires immediate intervention?
A. Headache
B. Nausea
C. Unequal pupils
D. Mild photophobia
Answer: C. Unequal pupils
Rationale: New unequal pupils may indicate worsening intracranial
pressure and possible brain herniation.
5. A client with a spinal cord injury suddenly develops severe
hypertension, headache, and flushing above the level of injury. Which
action should the nurse take first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Encourage oral fluids
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.
,6. A client with Addison disease develops severe weakness,
hypotension, vomiting, and confusion. Which complication should the
nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. SIADH
D. Diabetes insipidus
Answer: B. Addisonian crisis
Rationale: Acute adrenal insufficiency can cause profound hypotension,
weakness, gastrointestinal symptoms, electrolyte abnormalities, and
altered mental status.
7. Which finding is most concerning in a client with hyperthyroidism?
A. Heart rate of 118/min
B. Temperature of 103.5°F (39.7°C)
C. Increased appetite
D. Fine tremor
Answer: B. Temperature of 103.5°F (39.7°C)
Rationale: High fever, tachycardia, and severe hypermetabolic
symptoms may indicate thyroid storm, a life-threatening emergency.
8. A client with chronic obstructive pulmonary disease has an oxygen
saturation of 86%. Which oxygen prescription is most appropriate
initially?
A. 100% oxygen by nonrebreather mask
B. Low-flow oxygen as prescribed
C. No oxygen because of respiratory drive concerns
D. Oxygen at 15 L/min by nasal cannula
Answer: B. Low-flow oxygen as prescribed
, Rationale: Oxygen should be carefully titrated in clients with COPD
while maintaining adequate oxygenation and monitoring respiratory
status.
9. A client with a chest tube suddenly has continuous bubbling in the
water-seal chamber. What should the nurse do first?
A. Clamp the chest tube
B. Check the system for an air leak
C. Remove the chest tube
D. Increase suction
Answer: B. Check the system for an air leak
Rationale: Continuous bubbling may indicate an air leak in the system
or from the client. The nurse should assess connections and tubing first.
10. A client with a suspected tension pneumothorax develops severe
respiratory distress and hypotension. Which intervention should the
nurse anticipate?
A. Immediate needle decompression
B. Incentive spirometry
C. Oral antibiotics
D. Fluid restriction
Answer: A. Immediate needle decompression
Rationale: Tension pneumothorax is life-threatening and requires
immediate decompression to relieve pressure on the lung and
cardiovascular structures.
11. A client with acute heart failure has severe dyspnea and crackles
throughout both lungs. Which medication would the nurse expect to
administer?
A. Furosemide
B. Ferrous sulfate
Exam 2 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with acute pulmonary edema is severely dyspneic and has an
oxygen saturation of 82%. Which action should the nurse take first?
A. Obtain a chest x-ray
B. Place the client in high-Fowler's position
C. Administer a prescribed diuretic
D. Restrict oral fluids
Answer: B. Place the client in high-Fowler's position
Rationale: High-Fowler's positioning promotes lung expansion and
decreases venous return, helping improve oxygenation rapidly.
2. A client with diabetic ketoacidosis has a potassium level of 2.8
mEq/L. Which prescription should the nurse question?
A. IV regular insulin
B. Cardiac monitoring
C. IV potassium replacement
D. 0.9% sodium chloride infusion
Answer: A. IV regular insulin
Rationale: Insulin drives potassium into cells and can worsen severe
hypokalemia. Potassium should be corrected before insulin is
administered when the serum potassium is critically low.
3. A client develops sudden facial drooping, slurred speech, and
weakness of the right arm. What is the nurse's priority action?
,A. Give aspirin immediately
B. Determine the time symptoms began
C. Place the client in Trendelenburg position
D. Administer oral fluids
Answer: B. Determine the time symptoms began
Rationale: The onset time is critical in determining eligibility for time-
sensitive stroke therapies.
4. A client with increased intracranial pressure is being monitored.
Which finding requires immediate intervention?
A. Headache
B. Nausea
C. Unequal pupils
D. Mild photophobia
Answer: C. Unequal pupils
Rationale: New unequal pupils may indicate worsening intracranial
pressure and possible brain herniation.
5. A client with a spinal cord injury suddenly develops severe
hypertension, headache, and flushing above the level of injury. Which
action should the nurse take first?
A. Place the client flat
B. Sit the client upright
C. Administer a sedative
D. Encourage oral fluids
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.
,6. A client with Addison disease develops severe weakness,
hypotension, vomiting, and confusion. Which complication should the
nurse suspect?
A. Thyroid storm
B. Addisonian crisis
C. SIADH
D. Diabetes insipidus
Answer: B. Addisonian crisis
Rationale: Acute adrenal insufficiency can cause profound hypotension,
weakness, gastrointestinal symptoms, electrolyte abnormalities, and
altered mental status.
7. Which finding is most concerning in a client with hyperthyroidism?
A. Heart rate of 118/min
B. Temperature of 103.5°F (39.7°C)
C. Increased appetite
D. Fine tremor
Answer: B. Temperature of 103.5°F (39.7°C)
Rationale: High fever, tachycardia, and severe hypermetabolic
symptoms may indicate thyroid storm, a life-threatening emergency.
8. A client with chronic obstructive pulmonary disease has an oxygen
saturation of 86%. Which oxygen prescription is most appropriate
initially?
A. 100% oxygen by nonrebreather mask
B. Low-flow oxygen as prescribed
C. No oxygen because of respiratory drive concerns
D. Oxygen at 15 L/min by nasal cannula
Answer: B. Low-flow oxygen as prescribed
, Rationale: Oxygen should be carefully titrated in clients with COPD
while maintaining adequate oxygenation and monitoring respiratory
status.
9. A client with a chest tube suddenly has continuous bubbling in the
water-seal chamber. What should the nurse do first?
A. Clamp the chest tube
B. Check the system for an air leak
C. Remove the chest tube
D. Increase suction
Answer: B. Check the system for an air leak
Rationale: Continuous bubbling may indicate an air leak in the system
or from the client. The nurse should assess connections and tubing first.
10. A client with a suspected tension pneumothorax develops severe
respiratory distress and hypotension. Which intervention should the
nurse anticipate?
A. Immediate needle decompression
B. Incentive spirometry
C. Oral antibiotics
D. Fluid restriction
Answer: A. Immediate needle decompression
Rationale: Tension pneumothorax is life-threatening and requires
immediate decompression to relieve pressure on the lung and
cardiovascular structures.
11. A client with acute heart failure has severe dyspnea and crackles
throughout both lungs. Which medication would the nurse expect to
administer?
A. Furosemide
B. Ferrous sulfate
