NCLEX RN Physiological Adaptation
Exam 4 100 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 prescription should
the nurse implement first?
A. Administer IV isotonic crystalloid
B. Administer a loop diuretic
C. Restrict oral fluids
D. Place the client in a warm bath
Answer: Administer IV isotonic crystalloid
Rationale: Rapid administration of isotonic fluids is a priority in hypovolemic
shock because it restores intravascular volume and improves tissue perfusion.
2. A client with diabetic ketoacidosis has a potassium level of 3.1 mEq/L
before insulin therapy. Which action is most appropriate?
A. Start the insulin infusion immediately
B. Administer prescribed potassium replacement
C. Restrict potassium intake
D. Administer sodium bicarbonate routinely
Answer: Administer prescribed potassium replacement
Rationale: Insulin drives potassium into cells and can worsen hypokalemia.
Significant hypokalemia should be corrected before or while carefully
initiating insulin therapy according to the prescribed protocol.
, 3. A client with increased intracranial pressure suddenly develops
bradycardia, widening pulse pressure, and irregular respirations. How
should the nurse interpret these findings?
A. Neurogenic shock
B. Cushing response
C. Hypovolemic shock
D. Septic shock
Answer: Cushing response
Rationale: Bradycardia, widened pulse pressure, and abnormal respirations
are classic manifestations of increased intracranial pressure and impending
brain herniation.
4. A client with a spinal cord injury has hypotension, bradycardia, and
warm, dry skin. Which condition should the nurse suspect?
A. Septic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Hypovolemic shock
Answer: Neurogenic shock
Rationale: Neurogenic shock results from loss of sympathetic vascular tone
after spinal cord injury, producing hypotension, bradycardia, and warm, dry
skin.
5. A client with suspected sepsis has a temperature of 39.4°C (102.9°F),
respiratory rate of 30/min, and altered mental status. Which intervention
is a priority?
A. Delay treatment until culture results return
B. Obtain cultures and administer prescribed broad-spectrum antibiotics
promptly
C. Restrict fluids
D. Encourage ambulation
Answer: Obtain cultures and administer prescribed broad-spectrum
antibiotics promptly
,Rationale: Early cultures and timely broad-spectrum antimicrobial therapy
are essential in suspected sepsis. Treatment should not be unnecessarily
delayed while awaiting culture results.
6. A client with acute pulmonary edema is severely dyspneic and coughing
frothy pink sputum. Which position should the nurse use?
A. Supine
B. Trendelenburg
C. High-Fowler's position
D. Prone
Answer: High-Fowler's position
Rationale: High-Fowler's positioning decreases venous return and improves
lung expansion, helping reduce respiratory distress associated with
pulmonary edema.
7. A client develops sudden chest pain, dyspnea, and tachycardia after hip
surgery. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Pneumothorax
C. Atelectasis only
D. Pulmonary edema from heart failure
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, and tachycardia after orthopedic
surgery are concerning for pulmonary embolism caused by venous
thromboembolism.
8. A client with a chest tube suddenly has severe dyspnea and absent
breath sounds on the affected side. What should the nurse do first?
A. Clamp the chest tube
B. Assess the tubing for obstruction or disconnection
C. Remove the chest tube
D. Place the client flat
Answer: Assess the tubing for obstruction or disconnection
, Rationale: Sudden respiratory deterioration may indicate a chest tube system
problem or recurrent pneumothorax. The nurse should rapidly assess the
system and the client.
9. A client with a tracheostomy has thick secretions and increasing
respiratory distress. Which intervention is most appropriate?
A. Suction the tracheostomy as indicated
B. Remove the tracheostomy tube permanently
C. Give oral fluids immediately
D. Deflate the cuff and leave it deflated
Answer: Suction the tracheostomy as indicated
Rationale: Thick secretions can obstruct the airway. Appropriate
tracheostomy suctioning helps remove secretions and restore airway patency.
10.A client with acute respiratory distress syndrome requires mechanical
ventilation. Which strategy is commonly used to reduce ventilator-
induced lung injury?
A. Very high tidal volumes
B. Low tidal-volume ventilation
C. Elimination of positive end-expiratory pressure
D. Routine hyperventilation
Answer: Low tidal-volume ventilation
Rationale: Lung-protective ventilation using lower tidal volumes reduces
alveolar overdistention and ventilator-induced lung injury in ARDS.
11.A client with severe asthma has a markedly diminished wheezing sound
and increasing respiratory fatigue. What does this finding indicate?
A. Improvement
B. Impending respiratory failure
C. Adequate ventilation
D. Resolution of bronchospasm
Answer: Impending respiratory failure
Exam 4 100 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 prescription should
the nurse implement first?
A. Administer IV isotonic crystalloid
B. Administer a loop diuretic
C. Restrict oral fluids
D. Place the client in a warm bath
Answer: Administer IV isotonic crystalloid
Rationale: Rapid administration of isotonic fluids is a priority in hypovolemic
shock because it restores intravascular volume and improves tissue perfusion.
2. A client with diabetic ketoacidosis has a potassium level of 3.1 mEq/L
before insulin therapy. Which action is most appropriate?
A. Start the insulin infusion immediately
B. Administer prescribed potassium replacement
C. Restrict potassium intake
D. Administer sodium bicarbonate routinely
Answer: Administer prescribed potassium replacement
Rationale: Insulin drives potassium into cells and can worsen hypokalemia.
Significant hypokalemia should be corrected before or while carefully
initiating insulin therapy according to the prescribed protocol.
, 3. A client with increased intracranial pressure suddenly develops
bradycardia, widening pulse pressure, and irregular respirations. How
should the nurse interpret these findings?
A. Neurogenic shock
B. Cushing response
C. Hypovolemic shock
D. Septic shock
Answer: Cushing response
Rationale: Bradycardia, widened pulse pressure, and abnormal respirations
are classic manifestations of increased intracranial pressure and impending
brain herniation.
4. A client with a spinal cord injury has hypotension, bradycardia, and
warm, dry skin. Which condition should the nurse suspect?
A. Septic shock
B. Cardiogenic shock
C. Neurogenic shock
D. Hypovolemic shock
Answer: Neurogenic shock
Rationale: Neurogenic shock results from loss of sympathetic vascular tone
after spinal cord injury, producing hypotension, bradycardia, and warm, dry
skin.
5. A client with suspected sepsis has a temperature of 39.4°C (102.9°F),
respiratory rate of 30/min, and altered mental status. Which intervention
is a priority?
A. Delay treatment until culture results return
B. Obtain cultures and administer prescribed broad-spectrum antibiotics
promptly
C. Restrict fluids
D. Encourage ambulation
Answer: Obtain cultures and administer prescribed broad-spectrum
antibiotics promptly
,Rationale: Early cultures and timely broad-spectrum antimicrobial therapy
are essential in suspected sepsis. Treatment should not be unnecessarily
delayed while awaiting culture results.
6. A client with acute pulmonary edema is severely dyspneic and coughing
frothy pink sputum. Which position should the nurse use?
A. Supine
B. Trendelenburg
C. High-Fowler's position
D. Prone
Answer: High-Fowler's position
Rationale: High-Fowler's positioning decreases venous return and improves
lung expansion, helping reduce respiratory distress associated with
pulmonary edema.
7. A client develops sudden chest pain, dyspnea, and tachycardia after hip
surgery. Which complication should the nurse suspect?
A. Pulmonary embolism
B. Pneumothorax
C. Atelectasis only
D. Pulmonary edema from heart failure
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, chest pain, and tachycardia after orthopedic
surgery are concerning for pulmonary embolism caused by venous
thromboembolism.
8. A client with a chest tube suddenly has severe dyspnea and absent
breath sounds on the affected side. What should the nurse do first?
A. Clamp the chest tube
B. Assess the tubing for obstruction or disconnection
C. Remove the chest tube
D. Place the client flat
Answer: Assess the tubing for obstruction or disconnection
, Rationale: Sudden respiratory deterioration may indicate a chest tube system
problem or recurrent pneumothorax. The nurse should rapidly assess the
system and the client.
9. A client with a tracheostomy has thick secretions and increasing
respiratory distress. Which intervention is most appropriate?
A. Suction the tracheostomy as indicated
B. Remove the tracheostomy tube permanently
C. Give oral fluids immediately
D. Deflate the cuff and leave it deflated
Answer: Suction the tracheostomy as indicated
Rationale: Thick secretions can obstruct the airway. Appropriate
tracheostomy suctioning helps remove secretions and restore airway patency.
10.A client with acute respiratory distress syndrome requires mechanical
ventilation. Which strategy is commonly used to reduce ventilator-
induced lung injury?
A. Very high tidal volumes
B. Low tidal-volume ventilation
C. Elimination of positive end-expiratory pressure
D. Routine hyperventilation
Answer: Low tidal-volume ventilation
Rationale: Lung-protective ventilation using lower tidal volumes reduces
alveolar overdistention and ventilator-induced lung injury in ARDS.
11.A client with severe asthma has a markedly diminished wheezing sound
and increasing respiratory fatigue. What does this finding indicate?
A. Improvement
B. Impending respiratory failure
C. Adequate ventilation
D. Resolution of bronchospasm
Answer: Impending respiratory failure
