NCLEX Physiological Adaptation Questions Answers

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:

Safe and Effective Care Environment

Health Promotion and Maintenance

Psychosocial Integrity