NCLEX-RN Physiological Adaptation Practice Questions

Managing acute and chronic conditions — shock, sepsis, fluid balance, and physiological crises. It sits under Physiological Integrity on the NCLEX-RN test plan and carries an approximate weight of 14% of the exam.

Below are 22 practice questions for this domain — 14 multiple-choice and 8 select-all-that-apply. Every item gives a rationale for each option, not just the correct one: on the NCLEX-RN the distractors are usually plausible actions that are simply lower priority, so knowing why an answer is wrong is worth as much as knowing why one is right.

How to use this page. Read the vignette, commit to an answer, and only then open “Show the answer and rationales”. Reading the worked answer first feels productive and teaches almost nothing — the recall attempt is what makes it stick.

Select-all-that-apply items are graded all-or-nothing: partial credit does not exist, so a single missed option loses the whole question.

Easy Select all that apply

1. Active tonic-clonic seizure — interventions

A nurse is at the bedside when a hospitalized client suddenly stiffens, loses consciousness, and begins generalized tonic-clonic jerking movements.

Which actions should the nurse take during the seizure? Select all that apply.

  1. Turn the client onto their side.
  2. Protect the head from injury with a pillow or padding.
  3. Note the time of onset and the duration of the seizure.
  4. Loosen restrictive clothing around the neck.
  5. Insert a padded tongue blade between the teeth.
  6. Restrain the client's arms and legs to stop the movements.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Side-lying positioning keeps the airway open and lets secretions drain, preventing aspiration during and after the seizure.
  • B. Correct . Cushioning the head prevents trauma from repeated contact with hard surfaces while the client is convulsing.
  • C. Correct . Timing the seizure is essential, since prolonged activity can become status epilepticus, and accurate documentation guides treatment.
  • D. Correct . Loosening tight clothing supports unobstructed breathing and reduces the risk of hypoxia during the event.
  • E. Incorrect . Never put anything in the mouth of a seizing client. It can break teeth, obstruct the airway, or injure the rescuer.
  • F. Incorrect . Restraining the limbs can cause fractures or soft-tissue injury. The movements are protected against, not forcibly stopped.

Reference: MedlinePlus (seizure first aid); CDC seizure first aid guidance

Easy Multiple choice

2. Dehydration risk — teaching evaluation

A nurse is teaching the family of an older adult client who was recently treated for dehydration after a viral illness. The nurse wants to confirm the family understands how to recognize early dehydration at home.

Which statement by a family member indicates correct understanding?

  1. We will watch for dark, concentrated urine and offer fluids before he feels thirsty.
  2. We should wait until he tells us he is thirsty before giving fluids.
  3. Pale, clear urine in large amounts is the first warning sign.
  4. We will limit his fluids if he starts feeling weak or dizzy.
Show the answer and rationales

Correct answer: A

  • A. Correct . Dark concentrated urine is an early sign of dehydration, and older adults have a blunted thirst response, so offering fluids proactively is correct.
  • B. Incorrect . Thirst is a late and unreliable signal in older adults. Waiting for it allows dehydration to progress before fluids are offered.
  • C. Incorrect . Pale, dilute urine indicates adequate hydration, not dehydration. Concentrated dark urine is the warning sign.
  • D. Incorrect . Weakness and dizziness can be signs of dehydration, so limiting fluids would worsen the problem. Fluids should be increased, not restricted.

Reference: MedlinePlus (dehydration); older-adult fluid balance

Easy Select all that apply

3. Iron-deficiency anemia — expected findings

A nurse is admitting a client with chronic iron-deficiency anemia whose hemoglobin is 7.4 g/dL. The nurse completes a focused assessment.

Which findings does the nurse expect to be consistent with this client's anemia? Select all that apply.

  1. Pallor of the skin and conjunctivae.
  2. Fatigue and weakness with activity.
  3. A resting heart rate of 108/min.
  4. Shortness of breath on exertion.
  5. A ruddy, flushed face.
  6. A capillary refill of less than 2 seconds.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Reduced hemoglobin lowers the oxygen-carrying capacity of the blood and decreases red color in the tissues, producing pallor of the skin and mucous membranes.
  • B. Correct . With less oxygen delivered to the tissues, the client tires easily. Fatigue and generalized weakness are hallmark symptoms of anemia.
  • C. Correct . The heart compensates for reduced oxygen-carrying capacity by pumping faster, so tachycardia is an expected finding in significant anemia.
  • D. Correct . Dyspnea on exertion reflects the body's struggle to meet oxygen demand when hemoglobin is low. It is a common and expected complaint in anemia.
  • E. Incorrect . A ruddy, plethoric appearance suggests an excess of red blood cells, as in polycythemia, which is the opposite of anemia.
  • F. Incorrect . Brisk capillary refill indicates good peripheral perfusion and is not an expected finding when oxygen-carrying capacity is reduced by anemia.

Reference: MedlinePlus (iron-deficiency anemia); anemia clinical manifestations

Easy Multiple choice

4. Orthostatic hypotension — teaching evaluation

A nurse is teaching an older adult client who became dizzy and nearly fainted when standing up quickly. The provider documented orthostatic hypotension, and the nurse reviews how to prevent it at home.

Which statement by the client indicates correct understanding of the teaching?

  1. I will sit on the edge of the bed for a moment before I stand up.
  2. I should stand up quickly so the dizziness passes faster.
  3. I will cut back on fluids to keep my blood pressure from dropping.
  4. If I feel lightheaded when I stand, I should keep walking to push through it.
Show the answer and rationales

Correct answer: A

  • A. Correct . Changing positions slowly and dangling the legs before standing gives the circulation time to adjust, which prevents the sudden blood pressure drop that causes dizziness and falls.
  • B. Incorrect . Standing up quickly triggers the blood pressure drop and worsens the dizziness, increasing the risk of a fall. Movement should be slow and deliberate.
  • C. Incorrect . Reducing fluids can cause dehydration, which lowers blood volume and makes orthostatic hypotension worse rather than better.
  • D. Incorrect . Continuing to walk while lightheaded risks a fall and injury. The client should sit or lie down until the symptoms pass.

Reference: Merck Manual (orthostatic hypotension); MedlinePlus (orthostatic hypotension)

Medium Multiple choice

5. Acute chest pain — first action

A client on a cardiac unit suddenly reports crushing substernal chest pressure radiating to the left arm, rated 8 out of 10. The client is anxious and slightly diaphoretic, with an oxygen saturation of 96 percent on room air.

Which action should the nurse take first?

  1. Obtain a 12-lead ECG and notify the provider.
  2. Apply supplemental oxygen at 4 L/min by nasal cannula.
  3. Have the client lie flat and remain on bed rest.
  4. Administer a stool softener to prevent straining.
Show the answer and rationales

Correct answer: A

  • A. Correct . The presentation suggests myocardial ischemia. A 12-lead ECG must be obtained quickly to identify ST changes so reperfusion can begin, because time is muscle. Rapid recognition drives treatment.
  • B. Incorrect . Routine oxygen is no longer recommended when saturation is at least 90 percent, and this client is at 96 percent. Oxygen would not address the ischemia and is unnecessary here.
  • C. Incorrect . Lying flat does not relieve ischemia or guide treatment. The priority is diagnostic evaluation and provider notification, not positioning.
  • D. Incorrect . Stool softeners may be used later to prevent Valsalva, but they do nothing for acute ischemia. This is not a first action.

Reference: 2025 ACC/AHA/ACEP/NAEMSP/SCAI Acute Coronary Syndromes Guideline

Medium Multiple choice

6. Anxiety-driven hyperventilation — first action

A nurse responds to a client having a panic episode who is breathing rapidly at a rate of 34/min. The client reports tingling around the mouth and in the fingertips and feels lightheaded. The arterial pH is 7.50 and the PaCO2 is 28 mmHg.

Which action should the nurse take first?

  1. Stay with the client and coach slow, controlled breathing.
  2. Have the client breathe into a paper bag to rebreathe carbon dioxide.
  3. Apply a non-rebreather mask at 15 L/min of oxygen.
  4. Prepare to administer a sedative before assessing the client further.
Show the answer and rationales

Correct answer: A

  • A. Correct . The findings show respiratory alkalosis from anxiety-driven hyperventilation, which blows off too much CO2. Staying present and coaching slow, controlled breathing calms the client and allows CO2 to return toward normal, correcting the imbalance safely.
  • B. Incorrect . Paper-bag rebreathing is no longer recommended. It risks dangerous hypoxia and can mask a serious underlying condition, so it is not a safe intervention.
  • C. Incorrect . High-flow oxygen does not address the problem. This client is hyperventilating and exhaling too much CO2, not suffering from low oxygen.
  • D. Incorrect . Sedating the client before a calm coaching attempt is premature and could depress respirations. Nonpharmacologic breathing support is the first step.

Reference: Cleveland Clinic (respiratory alkalosis); current guidance against paper-bag rebreathing

Medium Select all that apply

7. Chronic inflammatory disease — self-management teaching

A nurse is teaching a client with rheumatoid arthritis, a chronic inflammatory condition, about managing flares and recognizing complications at home.

Which statements by the client indicate correct understanding of managing chronic inflammation? Select all that apply.

  1. During a flare my joints may feel warm, swollen, red, and painful.
  2. I should report a new fever because it can signal an infection.
  3. I will take my anti-inflammatory medication as prescribed even between flares.
  4. I can stop my corticosteroid suddenly once I feel better.
  5. Chronic inflammation is harmless and never damages my body.
Show the answer and rationales

Correct answers: A, B, C

  • A. Correct . Warmth, swelling, redness, and pain are cardinal signs of the inflammatory response. Recognizing them helps the client identify a flare early.
  • B. Correct . Some treatments for chronic inflammation suppress the immune system, so a new fever may indicate infection and should be reported promptly.
  • C. Correct . Maintaining prescribed therapy helps control the ongoing inflammatory process and reduces joint damage over time, not just during flares.
  • D. Incorrect . Corticosteroids must be tapered, never stopped abruptly, to avoid adrenal insufficiency. Abrupt discontinuation is unsafe.
  • E. Incorrect . Unlike helpful acute inflammation, chronic inflammation is maladaptive and can progressively damage joints and tissues, which is why it requires ongoing management.

Reference: MedlinePlus (rheumatoid arthritis); chronic inflammation and corticosteroid teaching

Medium Multiple choice

8. Diabetic ketoacidosis — expected finding

A nurse is admitting a client with type 1 diabetes who has a blood glucose of 512 mg/dL, an arterial pH of 7.22, and serum bicarbonate of 14 mEq/L. The client is drowsy and breathing deeply and rapidly.

Which assessment finding does the nurse correctly attribute to compensation for this client's acid-base state?

  1. Deep, rapid Kussmaul respirations that blow off carbon dioxide.
  2. Slow, shallow breathing to retain carbon dioxide.
  3. A bounding pulse from carbon dioxide retention.
  4. Tetany and carpopedal spasm from a rising pH.
Show the answer and rationales

Correct answer: A

  • A. Correct . A pH of 7.22 with a low bicarbonate is metabolic acidosis from ketoacidosis. The lungs compensate with deep, rapid Kussmaul respirations that exhale CO2 to raise the pH back toward normal.
  • B. Incorrect . Retaining CO2 would add acid and worsen the acidosis. The body does the opposite here, increasing ventilation to remove acid.
  • C. Incorrect . This client is not retaining CO2, and a bounding pulse is not the respiratory compensation for metabolic acidosis. Kussmaul breathing is the hallmark response.
  • D. Incorrect . Tetany is associated with alkalosis and low ionized calcium. This client has acidosis, so a rising pH is not the process at work.

Reference: MedlinePlus (diabetic ketoacidosis); Kussmaul respiration physiology

Medium Select all that apply

9. Fluid volume deficit — assessment findings

A nurse is assessing a client who has had profuse watery diarrhea for two days and now reports feeling weak and dizzy. The nurse suspects a fluid volume deficit.

Which findings support the nurse's concern for a fluid volume deficit? Select all that apply.

  1. Dry mucous membranes and a sticky tongue.
  2. Poor skin turgor that tents when pinched.
  3. A urine specific gravity of 1.035.
  4. A heart rate of 116/min with a blood pressure of 96/58 mmHg.
  5. Distended jugular veins with the head of the bed elevated.
  6. Crackles heard in the bilateral lung bases.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Loss of body water dries the mucous membranes, a reliable early sign of fluid volume deficit.
  • B. Correct . Reduced interstitial fluid causes skin to remain tented after being pinched, reflecting a deficit in total body water.
  • C. Correct . The kidneys conserve water by concentrating the urine, so a specific gravity above 1.030 indicates significant dehydration.
  • D. Correct . As circulating volume falls, the heart speeds up to compensate and blood pressure drops, producing tachycardia with hypotension.
  • E. Incorrect . Jugular venous distention reflects fluid overload, not a deficit. With low volume the neck veins are flat.
  • F. Incorrect . Crackles indicate fluid in the alveoli from overload. They are not expected when the client has lost fluid.

Reference: MedlinePlus (dehydration); fluid volume deficit assessment

Medium Multiple choice

10. New hypothyroidism diagnosis — teaching evaluation

A nurse is teaching a client newly diagnosed with hypothyroidism who will begin levothyroxine. The nurse explains that the condition slows the body's metabolic rate.

Which statement by the client indicates correct understanding of how a slowed metabolism affects the body?

  1. I may feel cold, tired, and constipated, and I could gain weight.
  2. I should expect to feel hot, sweaty, and lose weight quickly.
  3. My heart rate will probably run fast all the time.
  4. I can stop the medication once I feel better in a few days.
Show the answer and rationales

Correct answer: A

  • A. Correct . A low metabolic rate reduces heat production and slows body processes, producing cold intolerance, fatigue, constipation, and weight gain. These are classic features of hypothyroidism.
  • B. Incorrect . Heat intolerance, sweating, and weight loss reflect an increased metabolic rate, as seen in hyperthyroidism. They are the opposite of what hypothyroidism causes.
  • C. Incorrect . A slowed metabolism tends to produce bradycardia, not a persistently fast heart rate. Tachycardia is associated with an overactive thyroid.
  • D. Incorrect . Levothyroxine is lifelong replacement therapy and should not be stopped when symptoms improve. Stopping it would allow the metabolic slowing to return.

Reference: MedlinePlus (hypothyroidism); levothyroxine patient teaching

Medium Multiple choice

11. Postoperative hypoxia — first action

A nurse enters the room of a client who is one hour postoperative from a laparoscopic cholecystectomy. The client is newly restless and confused, pulls at the bedrails, and has an oxygen saturation of 86 percent on room air.

Which action should the nurse take first?

  1. Apply supplemental oxygen and raise the head of the bed.
  2. Administer the ordered as-needed dose of opioid for pain.
  3. Apply soft wrist restraints to prevent the client from falling.
  4. Document the restlessness and reassess in 30 minutes.
Show the answer and rationales

Correct answer: A

  • A. Correct . Restlessness and confusion with an SpO2 of 86 percent are early signs of hypoxia. The immediate priority is to improve oxygenation by delivering oxygen and positioning the client upright to optimize ventilation.
  • B. Incorrect . Opioids depress respiration and would worsen hypoxia. Sedating a hypoxic, confused client is dangerous and addresses the wrong problem.
  • C. Incorrect . The restlessness is caused by hypoxia, not agitation. Restraining the client treats a symptom while the underlying oxygen deficit continues to worsen.
  • D. Incorrect . Delaying intervention for a hypoxic client is unsafe. Hypoxia is a medical emergency that requires immediate correction, not watchful waiting.

Reference: MedlinePlus (hypoxia); 2025 ACC/AHA guidance on oxygen therapy thresholds

Medium Multiple choice

12. Postoperative sinus tachycardia — first action

A nurse notes that a client who is four hours postoperative from an abdominal hysterectomy has a heart rate of 122/min in normal sinus rhythm. The blood pressure is 110/70 mmHg and the client appears restless.

Which action should the nurse take first?

  1. Assess the client for pain, bleeding, and fluid status.
  2. Prepare to administer a beta-blocker to slow the rate.
  3. Encourage the client to perform a vagal maneuver.
  4. Document the heart rate and recheck it in one hour.
Show the answer and rationales

Correct answer: A

  • A. Correct . Sinus tachycardia is usually a compensatory response, so the nurse must find the cause. Postoperatively the likely triggers are pain, hypovolemia from blood loss, or dehydration, and identifying which is present directs the correct treatment.
  • B. Incorrect . Slowing a compensatory sinus tachycardia with a beta-blocker can be dangerous, because it blunts the body's response to an underlying problem such as bleeding. The cause must be found and treated first.
  • C. Incorrect . Vagal maneuvers are used for certain supraventricular tachyarrhythmias, not for compensatory sinus tachycardia. They do not address the underlying cause and may be unsafe in a postoperative client.
  • D. Incorrect . Waiting an hour delays recognition of a potentially serious cause such as postoperative hemorrhage. Assessment, not delay, is the priority.

Reference: MedlinePlus (tachycardia); postoperative hemorrhage and hypovolemia assessment

Medium Multiple choice

13. Severe hypertension — finding to report immediately

A nurse is caring for a client on a medical unit whose blood pressure is now 198/124 mmHg on repeat measurement. The client has a history of chronic hypertension and takes a routine oral antihypertensive at home.

Which additional finding should the nurse report to the provider immediately?

  1. A sudden severe headache with blurred vision and new confusion.
  2. Mild fatigue that the client says is typical at this time of day.
  3. A report of feeling slightly anxious about being in the hospital.
  4. A capillary refill of 2 seconds in the fingertips.
Show the answer and rationales

Correct answer: A

  • A. Correct . A blood pressure above 180/120 mmHg paired with signs of acute target-organ damage, such as headache, visual changes, and altered mental status, defines a hypertensive emergency. This requires immediate provider notification and controlled IV blood pressure lowering.
  • B. Incorrect . Routine fatigue is nonspecific and does not indicate acute organ injury. It is not the finding that converts severe hypertension into an emergency.
  • C. Incorrect . Situational anxiety is common and may transiently raise blood pressure, but it is not evidence of target-organ damage and is not the priority to report.
  • D. Incorrect . A capillary refill of 2 seconds is normal and reassures adequate peripheral perfusion. It is not an alarming finding in this client.

Reference: 2025 AHA/ACC Hypertension Guideline; AHA scientific statement on elevated BP in acute care

Medium Select all that apply

14. Surgical wound infection — signs of inflammation

A nurse is assessing the surgical incision of a client on postoperative day four. The nurse suspects a developing wound infection with a local inflammatory response.

Which findings support the nurse's concern for an infected, inflamed wound? Select all that apply.

  1. Increasing redness spreading from the incision edges.
  2. Warmth of the skin around the incision.
  3. Purulent yellow-green drainage from the wound.
  4. A new temperature of 38.6 C.
  5. Approximated wound edges with a thin pink line of new tissue.
  6. A capillary refill of 2 seconds in the toes.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Redness, or rubor, is a cardinal sign of inflammation. Redness that spreads outward from the wound suggests an extending infectious process.
  • B. Correct . Heat, or calor, is a cardinal sign of inflammation. Localized warmth reflects increased blood flow to the infected, inflamed tissue.
  • C. Correct . Purulent drainage indicates infection. It is not part of normal healing and signals that organisms and white cells are accumulating in the wound.
  • D. Correct . A systemic fever reflects the body's inflammatory response to infection and raises concern that the wound infection may be progressing.
  • E. Incorrect . Well-approximated edges with pink new tissue describe normal healing by primary intention, not infection.
  • F. Incorrect . Normal distal capillary refill assesses perfusion, not wound infection, and is a reassuring finding unrelated to the inflamed incision.

Reference: MedlinePlus (surgical wound infection); cardinal signs of inflammation

Medium Multiple choice

15. Symptomatic bradycardia — first drug

A nurse is monitoring a client on a telemetry unit whose heart rate has dropped to 38/min. The client reports dizziness and is diaphoretic, with a blood pressure of 80/52 mmHg and a complaint of feeling faint.

After applying oxygen and notifying the provider, which intervention should the nurse anticipate first?

  1. Administer atropine 1 mg IV push.
  2. Prepare for immediate synchronized cardioversion.
  3. Administer a beta-blocker to stabilize the rhythm.
  4. Encourage the client to perform a vagal maneuver.
Show the answer and rationales

Correct answer: A

  • A. Correct . This client has symptomatic bradycardia with hypotension and dizziness. Atropine 1 mg IV is the first-line drug, repeated every 3 to 5 minutes up to a maximum of 3 mg per current ACLS guidance.
  • B. Incorrect . Cardioversion treats unstable tachyarrhythmias, not bradycardia. Shocking a slow rhythm is not indicated and would not raise the rate.
  • C. Incorrect . Beta-blockers slow the heart rate further and are contraindicated in bradycardia. Giving one would deepen the client's instability.
  • D. Incorrect . Vagal maneuvers slow the heart rate and are used for certain tachycardias. They would worsen this client's bradycardia.

Reference: 2020 AHA ACLS Adult Bradycardia Algorithm

Medium Select all that apply

16. Worsening heart failure — assessment findings

A nurse is assessing a client with chronic heart failure who reports increased shortness of breath over the past two days. The nurse suspects worsening fluid overload.

Which findings support the nurse's concern about fluid overload? Select all that apply.

  1. A weight gain of 2.3 kg since yesterday.
  2. New crackles auscultated in the bilateral lung bases.
  3. Pitting edema in both lower extremities.
  4. Distended jugular veins while the head of the bed is elevated.
  5. Flat neck veins and poor skin turgor.
  6. A urine specific gravity of 1.035.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Daily weight is the most accurate measure of fluid status, and roughly 1 kg equals about 1 L of fluid. A rapid gain of more than 2 kg signals fluid retention.
  • B. Correct . Crackles indicate fluid in the alveoli from pulmonary congestion, a classic sign of worsening left-sided heart failure.
  • C. Correct . Dependent pitting edema reflects excess interstitial fluid, consistent with fluid overload in heart failure.
  • D. Correct . Jugular venous distention reflects elevated right-sided filling pressures and systemic venous congestion, supporting fluid overload.
  • E. Incorrect . Flat neck veins and poor turgor indicate a fluid deficit, not overload. These findings point to dehydration instead.
  • F. Incorrect . A high specific gravity indicates concentrated urine seen in dehydration. Fluid overload is not characterized by this finding.

Reference: MedlinePlus (heart failure); daily weight as fluid-status measure

Hard Multiple choice

17. Casted extremity — finding to report

A nurse is performing neurovascular checks on a client who had a long-leg cast applied four hours ago for a tibial fracture. The client now rates the pain 9 out of 10 and says it is unrelieved by the prescribed opioid.

Which additional finding should the nurse report to the provider immediately?

  1. Pain on passive stretch of the toes with paresthesia in the foot.
  2. Mild itching of the skin beneath the cast edge.
  3. A capillary refill of 2 seconds in the casted toes.
  4. The client's report of feeling bored and asking for a television remote.
Show the answer and rationales

Correct answer: A

  • A. Correct . Severe pain out of proportion, pain on passive stretch, and paresthesia are early signs of compartment syndrome, a perfusion emergency. Ischemia becomes irreversible if pressure is not relieved promptly.
  • B. Incorrect . Itching under a cast is common and benign. It is not an indicator of compromised perfusion and does not require urgent reporting.
  • C. Incorrect . Capillary refill of 2 seconds is within normal limits and reassures that distal perfusion is currently adequate.
  • D. Incorrect . Boredom is unrelated to neurovascular status. It carries no clinical urgency.

Reference: MedlinePlus (compartment syndrome); neurovascular assessment (six Ps)

Hard Multiple choice

18. Hypovolemic shock — which client first

A nurse on a medical-surgical unit receives report on four clients at the start of the shift. All are due for assessment.

Which client should the nurse assess first?

  1. A client two hours post-abdominal surgery with a heart rate of 124/min, cool clammy skin, and new restlessness.
  2. A client with stable chronic hypertension whose blood pressure is 148/90 mmHg.
  3. A client with peripheral edema requesting help to elevate the legs.
  4. A client with a temperature of 37.8 C who is asking for the next dose of acetaminophen.
Show the answer and rationales

Correct answer: A

  • A. Correct . Tachycardia, cool clammy skin, and restlessness are early compensated signs of hypovolemic shock, possibly from internal bleeding. This client is deteriorating and must be assessed before perfusion fails.
  • B. Incorrect . This blood pressure is mildly elevated but stable and consistent with the client's baseline. It is not an emergent change.
  • C. Incorrect . Elevating edematous legs is appropriate but not urgent, and it does not signal physiologic deterioration. It can wait.
  • D. Incorrect . A low-grade fever with a routine medication request is a stable, non-urgent situation compared with a client showing early shock.

Reference: MedlinePlus (hypovolemic shock); compensated shock assessment

Hard Multiple choice

19. Metabolic alkalosis — expected compensation

A nurse is caring for a client who has had continuous nasogastric suction for three days after bowel surgery. The arterial pH is 7.52, the serum bicarbonate is 30 mEq/L, and the PaCO2 is 48 mmHg.

Which finding represents the expected respiratory compensation for this client's acid-base state?

  1. Slow, shallow breathing that retains carbon dioxide.
  2. Deep, rapid Kussmaul respirations that blow off carbon dioxide.
  3. A bounding pulse caused by the rising pH.
  4. Periods of apnea alternating with rapid deep breaths.
Show the answer and rationales

Correct answer: A

  • A. Correct . Loss of gastric acid through nasogastric suction causes metabolic alkalosis, shown by the high pH and elevated bicarbonate. The lungs compensate by hypoventilating, retaining CO2 to add acid and pull the pH back toward normal, which is why the PaCO2 is elevated.
  • B. Incorrect . Kussmaul breathing is the compensation for metabolic acidosis. Removing more CO2 here would raise the pH further and worsen the alkalosis.
  • C. Incorrect . A bounding pulse is not a respiratory compensation, and it is not how the body responds to metabolic alkalosis. The compensation is a change in ventilation, not pulse character.
  • D. Incorrect . Cheyne-Stokes type breathing reflects neurologic or severe cardiac compromise, not the steady hypoventilation that compensates for metabolic alkalosis.

Reference: MedlinePlus (metabolic alkalosis); acid-base compensation physiology

Hard Multiple choice

20. New atrial fibrillation — priority concern

A nurse is caring for a client whose cardiac monitor shows new atrial fibrillation with an irregularly irregular rhythm at a rate of 138/min. The client is alert with a blood pressure of 118/72 mmHg.

Which finding is the nurse's priority concern with this new rhythm?

  1. New onset of slurred speech and one-sided arm weakness.
  2. A pulse rate that is higher at the apex than at the wrist.
  3. The client's report of mild palpitations.
  4. A blood pressure of 118/72 mmHg.
Show the answer and rationales

Correct answer: A

  • A. Correct . In atrial fibrillation the atria quiver instead of contracting, so blood pools and can form a clot that travels to the brain. Slurred speech and arm weakness signal an embolic stroke, the most dangerous complication of this rhythm, and require immediate action.
  • B. Incorrect . A pulse deficit is an expected finding in atrial fibrillation because not every beat perfuses to the periphery. It should be assessed but is not the emergency here.
  • C. Incorrect . Palpitations are uncomfortable but common with a new fast rhythm. They are far less urgent than signs of an embolic stroke.
  • D. Incorrect . This blood pressure is within normal limits and reassuring. It does not represent instability from the arrhythmia.

Reference: MSD Manual (atrial fibrillation); AHA/ACC stroke prevention in atrial fibrillation

Hard Select all that apply

21. Septic shock — priority interventions

A nurse is caring for a client admitted with a urinary tract infection who now has a temperature of 39.4 C, heart rate 122/min, blood pressure 84/48 mmHg, respiratory rate 26/min, and a serum lactate of 4.2 mmol/L. The provider writes orders for the sepsis bundle.

Which interventions should the nurse carry out within the first hour? Select all that apply.

  1. Obtain blood cultures before administering antibiotics.
  2. Administer broad-spectrum IV antibiotics.
  3. Begin a 30 mL/kg IV crystalloid bolus.
  4. Remeasure the serum lactate to guide resuscitation.
  5. Restrict fluids and place the client flat to conserve volume.
  6. Hold antibiotics until culture sensitivities return.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Cultures must be drawn before antibiotics so the pathogen is not masked, as long as collection does not substantially delay the first dose. This is a core element of the hour-1 sepsis bundle.
  • B. Correct . Early broad-spectrum antibiotics are time-critical in sepsis because each hour of delay raises mortality. They are given as soon as possible within the first hour.
  • C. Correct . Hypotension and a lactate of 4.2 mmol/L indicate hypoperfusion, so rapid crystalloid resuscitation at 30 mL/kg is indicated to restore circulating volume and perfusion.
  • D. Correct . An elevated lactate reflects tissue hypoperfusion, and trending it tells the team whether resuscitation is working. The bundle calls for measuring lactate and rechecking it if the initial level is elevated.
  • E. Incorrect . Fluid restriction worsens the hypoperfusion of septic shock. The client needs aggressive fluid resuscitation, not restriction.
  • F. Incorrect . Waiting for sensitivities would delay treatment by a day or more and sharply increase mortality. Empiric broad-spectrum coverage starts now and is narrowed later.

Reference: Surviving Sepsis Campaign Hour-1 Bundle (2018 update, 2021 international guidelines)

Hard Select all that apply

22. Thyroid storm — recognizing the crisis

A nurse is caring for a client with Graves disease who underwent a stressful emergency procedure. The nurse suspects the client is developing thyroid storm, a severe hypermetabolic crisis.

Which findings would the nurse expect to support this concern? Select all that apply.

  1. A temperature of 40.2 C.
  2. A heart rate of 156/min.
  3. Severe agitation progressing to confusion.
  4. A blood pressure of 168/94 mmHg with a widened pulse pressure.
  5. Cold, dry skin with the client shivering.
  6. A heart rate of 52/min.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Thyroid storm drives the metabolic rate dangerously high, producing hyperthermia. A fever above 40 C is a hallmark of the crisis.
  • B. Correct . The surge of thyroid hormone overstimulates the heart, causing extreme tachycardia and often atrial fibrillation. A rate well above 140/min is typical.
  • C. Correct . The hypermetabolic state and central nervous system overstimulation cause altered mental status ranging from agitation and delirium to coma.
  • D. Correct . Increased cardiac output and adrenergic stimulation raise systolic blood pressure and widen the pulse pressure during thyroid storm.
  • E. Incorrect . Cold, dry skin reflects a low metabolic rate, as in hypothyroidism. Thyroid storm produces warm, flushed, diaphoretic skin instead.
  • F. Incorrect . Bradycardia is the opposite of what occurs in thyroid storm. The crisis drives the heart rate up, not down.

Reference: MedlinePlus (thyroid storm); endocrine hypermetabolic crisis clinical features

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