NCLEX Physiological Adaptation Questions Answers [Rationale]

Last Updated on July 4, 2024

NCLEX Physiological Adaptation Questions Answers [Rationale]. Free practice tests for the NCLEX-RN and NCLEX-PN exams. You can download the Physiological Adaptation under Physiological Integrity test in PDF format.

Physiological Integrity – Physiological Adaptation questions compose 11 to 17 percent of the NCLEX-RN.

This content relates to provision and management of care for patients with acute, chronic, or life-threatening conditions. Prepare for specific questions about medical emergencies, pathophysiology, hemodynamics, fluid and electrolyte imbalances, alterations in body systems, and unexpected responses to therapies.

NCLEX Physiological Adaptation Questions Answers

Q1. A nurse is assessing a client with severe dehydration. Which clinical manifestation should the nurse expect?

(A) Bradycardia
(B) Hypertension
(C) Tachycardia
(D) Increased urine output

View Answer

Answer: (C)
Rationale: Tachycardia is a common clinical manifestation of severe dehydration as the body tries to maintain cardiac output despite decreased fluid volume.

Q2. A client with congestive heart failure is receiving furosemide. Which laboratory value should the nurse monitor closely?

(A) Serum potassium
(B) Serum sodium
(C) Serum calcium
(D) Serum chloride

View Answer

Answer: (A)
Rationale: Furosemide is a diuretic that can cause significant potassium loss, leading to hypokalemia. Monitoring serum potassium levels is essential.

Q3. A client presents with a severe asthma exacerbation. Which medication should the nurse anticipate administering first?

(A) Oral corticosteroids
(B) Long-acting beta agonist
(C) Short-acting beta agonist
(D) Leukotriene inhibitor

View Answer

Answer: (C)
Rationale: Short-acting beta agonists, such as albuterol, are used as first-line treatment for acute asthma exacerbations to quickly relieve bronchospasm.

Q4. A client with chronic kidney disease is experiencing hyperkalemia. Which ECG change should the nurse expect to see?

(A) Prolonged QT interval
(B) Flattened T waves
(C) Peaked T waves
(D) ST segment depression

View Answer

Answer: (C)
Rationale: Hyperkalemia can cause characteristic ECG changes such as peaked T waves, which indicate elevated potassium levels.

Q5. A nurse is caring for a client with diabetes insipidus. Which assessment finding is most consistent with this condition?

(A) Oliguria
(B) Polyuria
(C) Weight gain
(D) Hypertension

View Answer

Answer: (B)
Rationale: Diabetes insipidus is characterized by excessive urination (polyuria) due to a deficiency of antidiuretic hormone (ADH).

Q6. A client is admitted with suspected acute pancreatitis. Which laboratory result supports this diagnosis?

(A) Elevated serum lipase
(B) Decreased serum amylase
(C) Elevated serum bilirubin
(D) Decreased serum calcium

View Answer

Answer: (A)
Rationale: Elevated serum lipase and amylase are indicative of acute pancreatitis.

Q7. A client with cirrhosis presents with confusion and altered level of consciousness. Which condition should the nurse suspect?

(A) Hepatorenal syndrome
(B) Hepatic encephalopathy
(C) Portal hypertension
(D) Esophageal varices

View Answer

Answer: (B)
Rationale: Hepatic encephalopathy is a complication of cirrhosis characterized by confusion and altered mental status due to the accumulation of toxins like ammonia.

Q8. A client with chronic obstructive pulmonary disease (COPD) is experiencing an exacerbation. Which intervention is the priority?

(A) Administering a high flow of oxygen
(B) Providing bronchodilators as prescribed
(C) Encouraging deep breathing and coughing
(D) Increasing fluid intake

View Answer

Answer: (B)
Rationale: Administering bronchodilators helps to open the airways and improve breathing during a COPD exacerbation.

Q9. A client with septic shock is receiving intravenous fluids. Which assessment finding indicates that the treatment is effective?

(A) Increased urine output
(B) Decreased respiratory rate
(C) Elevated blood pressure
(D) Reduced fever

View Answer

Answer: (C)
Rationale: An elevated blood pressure indicates improved perfusion and cardiac output, showing that fluid resuscitation is effective in septic shock.

Q10. A nurse is caring for a client with a traumatic brain injury. Which sign indicates increased intracranial pressure (ICP)?

(A) Bradycardia
(B) Tachycardia
(C) Hypotension
(D) Increased urine output

View Answer

Answer: (A)
Rationale: Bradycardia is a sign of increased intracranial pressure due to the Cushing reflex, which also includes hypertension and irregular respirations.

Q11. A nurse is monitoring a client post-thyroidectomy. Which assessment finding requires immediate intervention?

(A) Hoarseness
(B) Mild swelling at the incision site
(C) Tingling in the fingers and around the mouth
(D) Slight difficulty swallowing

View Answer

Answer: (C)
Rationale: Tingling in the fingers and around the mouth may indicate hypocalcemia due to accidental removal of or damage to the parathyroid glands, requiring immediate intervention.

Q12. A client is diagnosed with hyperthyroidism. Which symptom should the nurse expect to find?

(A) Cold intolerance
(B) Weight gain
(C) Bradycardia
(D) Heat intolerance

View Answer

Answer: (D)
Rationale: Heat intolerance is a common symptom of hyperthyroidism due to increased metabolic rate.

Q13. A nurse is caring for a client with acute kidney injury (AKI). Which laboratory finding is consistent with this condition?

(A) Decreased creatinine
(B) Elevated blood urea nitrogen (BUN)
(C) Decreased potassium
(D) Elevated calcium

View Answer

Answer: (B)
Rationale: Elevated blood urea nitrogen (BUN) and creatinine are indicative of impaired kidney function in acute kidney injury.

Q14. A client with heart failure presents with severe shortness of breath and pink, frothy sputum. Which condition should the nurse suspect?

(A) Pulmonary embolism
(B) Pleural effusion
(C) Pulmonary edema
(D) Chronic bronchitis

View Answer

Answer: (C)
Rationale: Severe shortness of breath and pink, frothy sputum are classic signs of pulmonary edema, a complication of heart failure.

Q15. A nurse is assessing a client with diabetic ketoacidosis (DKA). Which finding is expected?

(A) Bradycardia
(B) Fruity breath odor
(C) Hypoglycemia
(D) Oliguria

View Answer

Answer: (B)
Rationale: Fruity breath odor is a characteristic sign of diabetic ketoacidosis due to the presence of acetone.

Q16. A client with cirrhosis is experiencing ascites. Which intervention should the nurse anticipate?

(A) Administering a diuretic
(B) Encouraging a high-sodium diet
(C) Increasing fluid intake
(D) Providing a high-protein diet

View Answer

Answer: (A)
Rationale: Administering a diuretic helps reduce fluid accumulation in the abdomen associated with ascites.

Q17. A client with pneumonia is experiencing pleuritic chest pain. Which intervention is most appropriate to alleviate the pain?

(A) Encouraging deep breathing exercises
(B) Administering analgesics as prescribed
(C) Providing a high-protein diet
(D) Positioning the client flat in bed

View Answer

Answer: (B)
Rationale: Administering analgesics as prescribed helps alleviate pleuritic chest pain associated with pneumonia.

Q18. A nurse is caring for a client with hypovolemic shock. Which finding indicates that treatment has been effective?

(A) Increased heart rate
(B) Decreased urine output
(C) Stabilized blood pressure
(D) Pale, cool skin

View Answer

Answer: (C)
Rationale: Stabilized blood pressure indicates effective treatment of hypovolemic shock and improved perfusion.

Q19. A client with a history of seizures is taking phenytoin. Which side effect should the nurse monitor for?

(A) Hyperglycemia
(B) Gingival hyperplasia
(C) Hypotension
(D) Weight gain

View Answer

Answer: (B)
Rationale: Gingival hyperplasia is a common side effect of phenytoin and requires monitoring and dental care.

Q20. A client with a spinal cord injury at T6 experiences a sudden increase in blood pressure and severe headache. What should the nurse suspect?

(A) Myocardial infarction
(B) Autonomic dysreflexia
(C) Pulmonary embolism
(D) Stroke

View Answer

Answer: (B)
Rationale: Autonomic dysreflexia is a potentially life-threatening condition common in clients with spinal cord injuries above T6, characterized by severe hypertension and headache.

Q21. A client with end-stage renal disease is receiving hemodialysis. Which complication should the nurse monitor for during the treatment?

(A) Hypercalcemia
(B) Hypertension
(C) Hypotension
(D) Hyperkalemia

View Answer

Answer: (C)
Rationale: Hypotension is a common complication during hemodialysis due to fluid shifts and removal of excess fluid.

Q22. A client with severe burns is at risk for hypovolemic shock. Which initial sign should the nurse monitor for?

(A) Bradycardia
(B) Hypotension
(C) Oliguria
(D) Increased urine output

View Answer

Answer: (C)
Rationale: Oliguria is an early sign of hypovolemic shock due to decreased renal perfusion and fluid loss.

Q23. A nurse is caring for a client with chronic liver disease. Which laboratory value should the nurse monitor to assess for hepatic encephalopathy?

(A) Serum ammonia
(B) Serum sodium
(C) Serum potassium
(D) Serum calcium

View Answer

Answer: (A)
Rationale: Elevated serum ammonia levels are associated with hepatic encephalopathy, a complication of chronic liver disease.

Q24. A client with Addison’s disease is experiencing an adrenal crisis. Which treatment is the priority?

(A) Administering intravenous corticosteroids
(B) Providing a high-protein diet
(C) Restricting fluid intake
(D) Administering insulin

View Answer

Answer: (A)
Rationale: Administering intravenous corticosteroids is the priority treatment for an adrenal crisis to replace deficient hormones.

Q25. A nurse is caring for a client with a history of atrial fibrillation who is at risk for thromboembolism. Which medication should the nurse anticipate administering?

(A) Heparin
(B) Furosemide
(C) Metoprolol
(D) Atorvastatin

View Answer

Answer: (A)
Rationale: Heparin is an anticoagulant used to prevent thromboembolism in clients with atrial fibrillation.

See also:

Free NCLEX Practice Test with Study Guide [UPDATED 2024-25]

Safe and Effective Care Environment

Health Promotion and Maintenance

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Psychosocial Integrity