NCLEX RN Physiological Adaptation
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with hypovolemic shock has a blood pressure of 82/48 mm
Hg, heart rate of 128/min, and cool, clammy skin. Which intervention
should the nurse anticipate first?
A. Administer a loop diuretic
B. Restrict oral fluids
C. Administer isotonic IV fluids
D. Place the client in a warm bath
Answer: C. Administer isotonic IV fluids
Isotonic fluids restore circulating volume and improve tissue perfusion in
hypovolemic shock.
2. Which finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: C. Decreased level of consciousness
Changes in consciousness can indicate worsening cerebral dysfunction
and increased intracranial pressure.
3. A client with diabetic ketoacidosis has a potassium level of 3.0
mEq/L. Which action is priority before administering IV insulin?
,A. Give sodium bicarbonate
B. Correct the hypokalemia as prescribed
C. Restrict fluids
D. Administer potassium-free fluids
Answer: B. Correct the hypokalemia as prescribed
Insulin shifts potassium into cells and can worsen hypokalemia,
potentially causing life-threatening dysrhythmias.
4. Which finding is characteristic of Addisonian crisis?
A. Severe hypertension
B. Hypernatremia
C. Hypotension and hyperkalemia
D. Bradycardia with fluid overload
Answer: C. Hypotension and hyperkalemia
Adrenal insufficiency causes deficient cortisol and aldosterone,
producing hypotension, sodium loss, and potassium retention.
5. A client with acute pulmonary edema is severely dyspneic. Which
position is most appropriate?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Upright positioning decreases venous return and improves lung
expansion.
6. Which assessment finding suggests tension pneumothorax?
A. Bilateral crackles
B. Bradycardia
,C. Tracheal deviation and severe respiratory distress
D. Productive cough
Answer: C. Tracheal deviation and severe respiratory distress
Tension pneumothorax causes increasing intrathoracic pressure and can
shift the mediastinum.
7. A client with a chest tube suddenly has continuous bubbling in the
water-seal chamber. What should the nurse assess first?
A. The client's temperature
B. The chest-tube system for an air leak
C. The client's urine output
D. The client's bowel sounds
Answer: B. The chest-tube system for an air leak
Continuous bubbling in the water-seal chamber usually indicates an air
leak.
8. Which finding is expected in a client experiencing hypoglycemia?
A. Warm, dry skin
B. Kussmaul respirations
C. Diaphoresis and tremors
D. Fruity breath
Answer: C. Diaphoresis and tremors
Adrenergic stimulation during hypoglycemia produces sweating,
tremors, palpitations, and anxiety.
9. Which assessment finding is most consistent with hyperkalemia?
A. Muscle weakness
B. Peaked T waves
C. Flattened T waves
D. U waves
, Answer: B. Peaked T waves
Hyperkalemia can produce tall, peaked T waves and potentially fatal
cardiac dysrhythmias.
10. A client with severe asthma develops a very quiet chest. What does
this finding indicate?
A. Improvement
B. Mild bronchospasm
C. Severe airway obstruction
D. Normal ventilation
Answer: C. Severe airway obstruction
A markedly diminished or absent air movement can indicate impending
respiratory failure.
11. Which finding is typical of left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Left ventricular failure causes pulmonary congestion and fluid
accumulation in the lungs.
12. Which finding is most consistent with right-sided heart failure?
A. Pulmonary edema
B. Jugular venous distention
C. Pink frothy sputum
D. Severe pulmonary crackles
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
1. A client with hypovolemic shock has a blood pressure of 82/48 mm
Hg, heart rate of 128/min, and cool, clammy skin. Which intervention
should the nurse anticipate first?
A. Administer a loop diuretic
B. Restrict oral fluids
C. Administer isotonic IV fluids
D. Place the client in a warm bath
Answer: C. Administer isotonic IV fluids
Isotonic fluids restore circulating volume and improve tissue perfusion in
hypovolemic shock.
2. Which finding is most concerning in a client with increased
intracranial pressure?
A. Headache
B. Nausea
C. Decreased level of consciousness
D. Photophobia
Answer: C. Decreased level of consciousness
Changes in consciousness can indicate worsening cerebral dysfunction
and increased intracranial pressure.
3. A client with diabetic ketoacidosis has a potassium level of 3.0
mEq/L. Which action is priority before administering IV insulin?
,A. Give sodium bicarbonate
B. Correct the hypokalemia as prescribed
C. Restrict fluids
D. Administer potassium-free fluids
Answer: B. Correct the hypokalemia as prescribed
Insulin shifts potassium into cells and can worsen hypokalemia,
potentially causing life-threatening dysrhythmias.
4. Which finding is characteristic of Addisonian crisis?
A. Severe hypertension
B. Hypernatremia
C. Hypotension and hyperkalemia
D. Bradycardia with fluid overload
Answer: C. Hypotension and hyperkalemia
Adrenal insufficiency causes deficient cortisol and aldosterone,
producing hypotension, sodium loss, and potassium retention.
5. A client with acute pulmonary edema is severely dyspneic. Which
position is most appropriate?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Upright positioning decreases venous return and improves lung
expansion.
6. Which assessment finding suggests tension pneumothorax?
A. Bilateral crackles
B. Bradycardia
,C. Tracheal deviation and severe respiratory distress
D. Productive cough
Answer: C. Tracheal deviation and severe respiratory distress
Tension pneumothorax causes increasing intrathoracic pressure and can
shift the mediastinum.
7. A client with a chest tube suddenly has continuous bubbling in the
water-seal chamber. What should the nurse assess first?
A. The client's temperature
B. The chest-tube system for an air leak
C. The client's urine output
D. The client's bowel sounds
Answer: B. The chest-tube system for an air leak
Continuous bubbling in the water-seal chamber usually indicates an air
leak.
8. Which finding is expected in a client experiencing hypoglycemia?
A. Warm, dry skin
B. Kussmaul respirations
C. Diaphoresis and tremors
D. Fruity breath
Answer: C. Diaphoresis and tremors
Adrenergic stimulation during hypoglycemia produces sweating,
tremors, palpitations, and anxiety.
9. Which assessment finding is most consistent with hyperkalemia?
A. Muscle weakness
B. Peaked T waves
C. Flattened T waves
D. U waves
, Answer: B. Peaked T waves
Hyperkalemia can produce tall, peaked T waves and potentially fatal
cardiac dysrhythmias.
10. A client with severe asthma develops a very quiet chest. What does
this finding indicate?
A. Improvement
B. Mild bronchospasm
C. Severe airway obstruction
D. Normal ventilation
Answer: C. Severe airway obstruction
A markedly diminished or absent air movement can indicate impending
respiratory failure.
11. Which finding is typical of left-sided heart failure?
A. Ascites
B. Peripheral edema
C. Pulmonary crackles
D. Enlarged liver
Answer: C. Pulmonary crackles
Left ventricular failure causes pulmonary congestion and fluid
accumulation in the lungs.
12. Which finding is most consistent with right-sided heart failure?
A. Pulmonary edema
B. Jugular venous distention
C. Pink frothy sputum
D. Severe pulmonary crackles
