NCLEX RN Physiological Adaptation
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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Question 1
A client with heart failure suddenly develops severe dyspnea, crackles
throughout both lung fields, and pink, frothy sputum. Which action should the
nurse take first?
A. Obtain a daily weight
B. Place the client in high-Fowler’s position
C. Encourage oral fluids
D. Administer a prescribed oral diuretic
Answer: Place the client in high-Fowler’s position
Rationale: Positioning the client upright maximizes lung expansion and
decreases venous return, helping improve oxygenation during acute
pulmonary edema.
Question 2
A client with a tension pneumothorax is becoming hypotensive and severely
dyspneic. Which intervention should the nurse anticipate?
A. Incentive spirometry
B. Immediate chest tube insertion
C. Oral antibiotics
D. Fluid restriction
Answer: Immediate chest tube insertion
,Rationale: A tension pneumothorax causes increasing intrathoracic pressure
and cardiovascular compromise. Rapid decompression with a chest tube is
required.
Question 3
A client with diabetic ketoacidosis has a potassium level of 3.0 mEq/L. Which
prescription should the nurse question?
A. Begin IV isotonic fluids
B. Administer IV regular insulin immediately
C. Replace potassium as prescribed
D. Monitor cardiac rhythm
Answer: Administer IV regular insulin immediately
Rationale: Insulin shifts potassium into cells and can cause life-threatening
hypokalemia. Significant hypokalemia should be corrected before insulin is
administered.
Question 4
A client with increased intracranial pressure develops bradycardia,
hypertension, and irregular respirations. How should the nurse interpret these
findings?
A. Septic shock
B. Cushing response
C. Hypovolemic shock
D. Neurogenic shock
Answer: Cushing response
Rationale: The Cushing response consists of hypertension with widened pulse
pressure, bradycardia, and abnormal respirations and indicates increased
intracranial pressure.
Question 5
A client with an acute myocardial infarction reports crushing substernal chest
pain. Which prescribed medication should the nurse administer first when not
contraindicated?
,A. Morphine
B. Sublingual nitroglycerin
C. Warfarin
D. Furosemide
Answer: Sublingual nitroglycerin
Rationale: Nitroglycerin decreases myocardial oxygen demand and can
relieve ischemic chest pain by causing vasodilation. Blood pressure and
contraindications must be assessed first.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen. Which
finding requires immediate intervention?
A. Oxygen saturation of 90%
B. Respiratory rate of 20/min
C. Increasing somnolence and confusion
D. Mild exertional dyspnea
Answer: Increasing somnolence and confusion
Rationale: Increasing somnolence and confusion may indicate worsening
carbon dioxide retention and respiratory failure, requiring immediate
assessment.
Question 7
A client with severe asthma has minimal air movement and suddenly becomes
quiet after prolonged wheezing. What does this finding indicate?
A. Improvement
B. Anxiety reduction
C. Severe airway obstruction
D. Resolution of bronchospasm
Answer: Severe airway obstruction
Rationale: A “silent chest” in a client with severe asthma indicates critically
reduced airflow and impending respiratory failure.
Question 8
, A client with a chest tube develops continuous bubbling in the water-seal
chamber. What should the nurse do?
A. Clamp the chest tube
B. Check the system for an air leak
C. Increase suction pressure
D. Remove the chest tube
Answer: Check the system for an air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak. The nurse should assess connections and the insertion site.
Question 9
A client with acute pancreatitis reports severe abdominal pain radiating to the
back. Which intervention is appropriate?
A. Encourage a high-fat meal
B. Maintain prescribed pancreatic rest
C. Encourage alcohol intake
D. Apply vigorous abdominal massage
Answer: Maintain prescribed pancreatic rest
Rationale: Pancreatic rest decreases stimulation of pancreatic enzyme
secretion and is commonly part of management of acute pancreatitis.
Question 10
A client with cirrhosis becomes confused and has asterixis. Which laboratory
value is most relevant?
A. Serum ammonia
B. Serum calcium
C. Troponin
D. Hemoglobin A1c
Answer: Serum ammonia
Rationale: Increased ammonia levels contribute to hepatic encephalopathy,
which can cause confusion and asterixis in clients with severe liver
dysfunction.
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
Question 1
A client with heart failure suddenly develops severe dyspnea, crackles
throughout both lung fields, and pink, frothy sputum. Which action should the
nurse take first?
A. Obtain a daily weight
B. Place the client in high-Fowler’s position
C. Encourage oral fluids
D. Administer a prescribed oral diuretic
Answer: Place the client in high-Fowler’s position
Rationale: Positioning the client upright maximizes lung expansion and
decreases venous return, helping improve oxygenation during acute
pulmonary edema.
Question 2
A client with a tension pneumothorax is becoming hypotensive and severely
dyspneic. Which intervention should the nurse anticipate?
A. Incentive spirometry
B. Immediate chest tube insertion
C. Oral antibiotics
D. Fluid restriction
Answer: Immediate chest tube insertion
,Rationale: A tension pneumothorax causes increasing intrathoracic pressure
and cardiovascular compromise. Rapid decompression with a chest tube is
required.
Question 3
A client with diabetic ketoacidosis has a potassium level of 3.0 mEq/L. Which
prescription should the nurse question?
A. Begin IV isotonic fluids
B. Administer IV regular insulin immediately
C. Replace potassium as prescribed
D. Monitor cardiac rhythm
Answer: Administer IV regular insulin immediately
Rationale: Insulin shifts potassium into cells and can cause life-threatening
hypokalemia. Significant hypokalemia should be corrected before insulin is
administered.
Question 4
A client with increased intracranial pressure develops bradycardia,
hypertension, and irregular respirations. How should the nurse interpret these
findings?
A. Septic shock
B. Cushing response
C. Hypovolemic shock
D. Neurogenic shock
Answer: Cushing response
Rationale: The Cushing response consists of hypertension with widened pulse
pressure, bradycardia, and abnormal respirations and indicates increased
intracranial pressure.
Question 5
A client with an acute myocardial infarction reports crushing substernal chest
pain. Which prescribed medication should the nurse administer first when not
contraindicated?
,A. Morphine
B. Sublingual nitroglycerin
C. Warfarin
D. Furosemide
Answer: Sublingual nitroglycerin
Rationale: Nitroglycerin decreases myocardial oxygen demand and can
relieve ischemic chest pain by causing vasodilation. Blood pressure and
contraindications must be assessed first.
Question 6
A client with chronic obstructive pulmonary disease is receiving oxygen. Which
finding requires immediate intervention?
A. Oxygen saturation of 90%
B. Respiratory rate of 20/min
C. Increasing somnolence and confusion
D. Mild exertional dyspnea
Answer: Increasing somnolence and confusion
Rationale: Increasing somnolence and confusion may indicate worsening
carbon dioxide retention and respiratory failure, requiring immediate
assessment.
Question 7
A client with severe asthma has minimal air movement and suddenly becomes
quiet after prolonged wheezing. What does this finding indicate?
A. Improvement
B. Anxiety reduction
C. Severe airway obstruction
D. Resolution of bronchospasm
Answer: Severe airway obstruction
Rationale: A “silent chest” in a client with severe asthma indicates critically
reduced airflow and impending respiratory failure.
Question 8
, A client with a chest tube develops continuous bubbling in the water-seal
chamber. What should the nurse do?
A. Clamp the chest tube
B. Check the system for an air leak
C. Increase suction pressure
D. Remove the chest tube
Answer: Check the system for an air leak
Rationale: Continuous bubbling in the water-seal chamber usually indicates
an air leak. The nurse should assess connections and the insertion site.
Question 9
A client with acute pancreatitis reports severe abdominal pain radiating to the
back. Which intervention is appropriate?
A. Encourage a high-fat meal
B. Maintain prescribed pancreatic rest
C. Encourage alcohol intake
D. Apply vigorous abdominal massage
Answer: Maintain prescribed pancreatic rest
Rationale: Pancreatic rest decreases stimulation of pancreatic enzyme
secretion and is commonly part of management of acute pancreatitis.
Question 10
A client with cirrhosis becomes confused and has asterixis. Which laboratory
value is most relevant?
A. Serum ammonia
B. Serum calcium
C. Troponin
D. Hemoglobin A1c
Answer: Serum ammonia
Rationale: Increased ammonia levels contribute to hepatic encephalopathy,
which can cause confusion and asterixis in clients with severe liver
dysfunction.
