NCLEX Physiological Adaptation Practice Test
What is in this test
| Topic | Focus | Items |
|---|---|---|
| Fluid and Electrolyte Balance | Volume status and the six key electrolytes | 4 |
| Endocrine Disorders | Diabetes, thyroid and adrenal conditions | 4 |
| Respiratory Disorders | Asthma, COPD, pneumonia and pneumothorax | 4 |
| Neurological Disorders | Stroke, seizures, spinal cord and raised pressure | 4 |
| Renal and Gastrointestinal Disorders | Kidney injury, dialysis, liver and bowel disease | 3 |
| Medical Emergencies | Shock, anaphylaxis, burns and trauma | 3 |
| Cardiac Disorders | Coronary syndrome, heart failure and dysrhythmias | 3 |
| Acid-Base Balance | Reading a blood gas in four steps | 2 |
Item formats in this test: Multiple choice, Select all that apply, Hot spot, Ordered response. This is test 7 of 9 — there is one for every client-need category.
The 27 questions
Which assessment finding best indicates that a client’s fluid volume deficit is improving?
Show answer and rationale
Correct answer: A. Urine specific gravity has fallen from 1.032 to 1.015
Urine specific gravity is an objective measure of how concentrated the urine is. A fall from 1.032 toward the middle of the normal range indicates the kidneys no longer need to conserve water aggressively.
Why the other options are wrong
- B. Reduced thirst is subjective and is unreliable, particularly in older adults.
- C. Moist mucosa is supportive but is a softer, more subjective finding than a measured value.
- D. Eating a meal indicates appetite, not hydration status.
A conscious client with diabetes has a blood glucose of 54 mg/dL and reports shakiness. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Give 15 grams of a fast-acting carbohydrate
For a conscious client with hypoglycaemia, 15 grams of fast-acting carbohydrate raises the glucose within minutes. The glucose is rechecked after 15 minutes and the dose repeated if still low, then followed with a complex carbohydrate and protein.
Why the other options are wrong
- B. Insulin lowers glucose further and would be dangerous.
- C. Fat and protein slow absorption, so a sandwich is the follow-up snack, not the immediate treatment.
- D. Intravenous dextrose is for an unconscious client or one who cannot swallow safely.
A client has a newly created arteriovenous fistula in the left forearm. Which assessment finding indicates the access is functioning?
Show answer and rationale
Correct answer: A. A palpable thrill and audible bruit over the site
A functioning fistula produces turbulent flow, felt as a thrill and heard as a bruit. Loss of either suggests the access has clotted and requires immediate reporting.
Why the other options are wrong
- B. A distal pulse is reassuring for perfusion but does not confirm the fistula itself is patent.
- C. Silence over the fistula suggests thrombosis.
- D. Coolness of the hand suggests steal syndrome, where the fistula diverts blood from the distal limb.
A client develops hives, wheezing and throat tightness minutes after an intravenous antibiotic is started. After stopping the infusion, which action should the nurse take next?
Show answer and rationale
Correct answer: A. Administer intramuscular epinephrine
Epinephrine is the only medication that reverses the airway oedema and vasodilation of anaphylaxis quickly. It is given intramuscularly into the outer thigh and repeated as needed.
Why the other options are wrong
- B. Antihistamines relieve hives but do nothing for airway oedema or hypotension.
- C. Corticosteroids take hours to act and are used to prevent a biphasic reaction.
- D. Waiting during a progressing airway reaction risks complete obstruction.
An arterial blood gas shows pH 7.28, PaCO2 58 mmHg, HCO3 25 mEq/L. Which condition does this represent?
Show answer and rationale
Correct answer: A. Respiratory acidosis, uncompensated
The pH of 7.28 is acidotic. The PaCO2 of 58 is elevated and moves in the opposite direction to the pH, which makes the cause respiratory. The bicarbonate of 25 is normal, so no compensation has occurred yet.
Why the other options are wrong
- B. In metabolic acidosis the bicarbonate would be low, not normal.
- C. Alkalosis requires a pH above 7.45.
- D. Full compensation would mean a normal pH, and the bicarbonate would be elevated.
A client with severe diarrhoea for three days is likely to develop which acid-base imbalance?
Show answer and rationale
Correct answer: C. Metabolic acidosis
Intestinal secretions are rich in bicarbonate. Losing large volumes of stool depletes bicarbonate and produces metabolic acidosis.
Why the other options are wrong
- A. Respiratory acidosis results from carbon dioxide retention, not from stool losses.
- B. Respiratory alkalosis results from hyperventilation.
- D. Metabolic alkalosis follows loss of gastric acid through vomiting or suction, which is the opposite end of the gut.
Which assessment findings would the nurse expect in a client with hypocalcaemia? Select all that apply.
- ACarpal spasm when a blood pressure cuff is inflated
- BFacial twitching when the cheek is tapped
- CAbsent deep tendon reflexes
- DNumbness and tingling around the mouth
- EMuscle cramps
Show answer and rationale
Correct answers: A. Carpal spasm when a blood pressure cuff is inflated; B. Facial twitching when the cheek is tapped; D. Numbness and tingling around the mouth; E. Muscle cramps
Low calcium increases neuromuscular excitability, producing the Trousseau sign, the Chvostek sign, perioral paraesthesia and cramping. Tetany and seizures occur at severe levels.
Why the other options are wrong
- C. Absent deep tendon reflexes indicate depressed neuromuscular activity, which is seen in hypercalcaemia and hypermagnesaemia.
Which findings are characteristic of left-sided heart failure? Select all that apply.
- ABibasilar crackles
- BOrthopnoea
- CJugular venous distension
- DPink frothy sputum
- EDependent peripheral oedema
Show answer and rationale
Correct answers: A. Bibasilar crackles; B. Orthopnoea; D. Pink frothy sputum
Left-sided failure backs blood up into the pulmonary circulation, producing crackles, orthopnoea, paroxysmal nocturnal dyspnoea and, in severe cases, pink frothy sputum.
Why the other options are wrong
- C. Jugular venous distension reflects systemic venous congestion from right-sided failure.
- E. Dependent oedema is a right-sided finding.
A client with heart failure suddenly becomes severely dyspnoeic and coughs up pink frothy sputum. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Place the client in a high Fowler position with legs dependent
Sitting upright with legs dependent maximises lung expansion and reduces venous return to the overloaded heart. It requires no order, takes seconds and directly addresses the breathing problem.
Why the other options are wrong
- B. An electrocardiogram is important but does not relieve the immediate respiratory distress.
- C. Laboratory confirmation is unnecessary before treating obvious acute pulmonary oedema.
- D. A catheter helps track diuresis later but does nothing for the immediate crisis.
A client with chronic obstructive pulmonary disease has an oxygen saturation of 90 percent on 2 litres by nasal cannula and is comfortable. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Continue the current flow rate and monitor
In chronic carbon dioxide retention the target saturation is generally 88 to 92 percent. A comfortable client at 90 percent is at goal, and the flow rate is left unchanged.
Why the other options are wrong
- A. Driving the saturation higher in a chronic retainer can worsen carbon dioxide retention and cause somnolence.
- C. Removing oxygen from a hypoxaemic client is unsafe.
- D. A high-concentration mask is for acute severe hypoxaemia, not a client at target and comfortable.
Which finding is the earliest indicator of increasing intracranial pressure?
Show answer and rationale
Correct answer: B. Change in level of consciousness
The cerebral cortex is the most sensitive area to pressure and hypoxia, so a subtle change in alertness, orientation or responsiveness appears well before any vital sign change.
Why the other options are wrong
- A. A widening pulse pressure is part of the Cushing triad, which is a late finding.
- C. Fixed dilated pupils indicate brainstem compression and are very late.
- D. Irregular respirations are also part of the late Cushing triad.
A client is admitted with a suspected ischaemic stroke. Which information is most critical for the nurse to establish?
Show answer and rationale
Correct answer: B. The exact time the client was last known to be well
Eligibility for thrombolytic therapy depends on a narrow time window from symptom onset. The last known well time determines whether that treatment can be offered, and it must be established immediately.
Why the other options are wrong
- A. Baseline blood pressure is useful context but does not gate the time-critical treatment decision.
- C. Family history informs long-term risk, not acute management.
- D. Diet matters later, and only after swallowing has been assessed.
Which findings would the nurse expect in a client with hypothyroidism? Select all that apply.
- AWeight gain despite a reduced appetite
- BCold intolerance
- CHeat intolerance and diaphoresis
- DConstipation
- EBradycardia
Show answer and rationale
Correct answers: A. Weight gain despite a reduced appetite; B. Cold intolerance; D. Constipation; E. Bradycardia
Hypothyroidism slows metabolic processes throughout the body, producing weight gain, cold intolerance, constipation, bradycardia, fatigue, dry skin and slowed cognition.
Why the other options are wrong
- C. Heat intolerance with sweating belongs to hyperthyroidism, where metabolism is accelerated.
A client with cirrhosis is receiving lactulose for hepatic encephalopathy. Which finding indicates the medication is effective?
Show answer and rationale
Correct answer: A. The client has had two to three soft stools today and is more oriented
Lactulose acidifies the bowel and traps ammonia for excretion, so the therapeutic endpoint is two to three soft stools a day. Improved orientation confirms the falling ammonia is reaching the brain.
Why the other options are wrong
- B. Lactulose commonly causes flatulence and bloating rather than relieving it.
- C. No bowel movement means the ammonia is not being excreted and the dose is inadequate.
- D. Albumin reflects hepatic synthetic function over weeks, not the immediate effect of lactulose.
A client arrives after a house fire with burns to the face, singed nasal hairs and a hoarse voice. Which is the nurse’s priority?
Show answer and rationale
Correct answer: B. Assess and secure the airway
Facial burns with singed nasal hair and hoarseness indicate inhalation injury. Airway oedema develops rapidly and can make intubation impossible if it is delayed, so the airway is assessed and secured first.
Why the other options are wrong
- A. Body surface area guides fluid volume, which comes after the airway.
- C. Fluid resuscitation is critical but follows airway management.
- D. Wound care is a later priority in the emergency phase.
A client has a serum sodium of 122 mEq/L and is increasingly confused. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: B. Institute seizure precautions and notify the provider
A sodium of 122 with confusion indicates cerebral oedema and a real risk of seizures. Seizure precautions protect the client while the provider directs correction, which must be gradual.
Why the other options are wrong
- A. Additional free water dilutes the sodium further and worsens the cerebral oedema.
- C. Correcting sodium too rapidly risks osmotic demyelination and permanent neurological injury.
- D. Complete withholding of intake is not indicated and does not address the immediate safety risk.
A nurse is preparing to suction a client’s tracheostomy. Which technique is correct?
Show answer and rationale
Correct answer: B. Hyperoxygenate first and apply suction only while withdrawing, for no more than 10 seconds
Hyperoxygenation before suctioning prevents hypoxaemia. Suction is applied only on withdrawal to avoid damaging mucosa, and each pass is limited to about 10 seconds because suctioning removes oxygen as well as secretions.
Why the other options are wrong
- A. Suctioning on insertion traumatises the tracheal mucosa.
- C. Thirty seconds of continuous suction causes significant hypoxaemia and can precipitate bradycardia.
- D. Routine saline instillation is not recommended; it does not thin secretions and can push organisms into the lower airway.
A client in the oliguric phase of acute kidney injury has a potassium of 5.9 mEq/L. Which meal choice should the nurse reinforce as most appropriate?
Show answer and rationale
Correct answer: B. White rice with green beans and canned pears in juice drained
White rice, green beans and drained canned pears are all low in potassium, which is what a client with hyperkalaemia and impaired renal excretion needs.
Why the other options are wrong
- A. Potatoes, spinach and bananas are all high in potassium.
- C. Tomatoes, avocado and orange juice are high in potassium.
- D. Sweet potatoes and dried fruit are concentrated potassium sources.
A client has a closed head injury with increased intracranial pressure. Select the head-of-bed position the nurse should maintain.
Show answer and rationale
Correct answer: C. 30 degrees
Elevating the head of the bed to about 30 degrees with the head midline promotes venous drainage from the brain without compromising cerebral perfusion pressure.
A client with acute kidney injury has a potassium level of 6.8 mEq/L and peaked T waves on the monitor. Which prescribed intervention should the nurse administer first?
Show answer and rationale
Correct answer: B. Intravenous calcium gluconate
Calcium gluconate does not lower potassium, but it stabilises the cardiac membrane within minutes and prevents lethal dysrhythmias. With ECG changes already present, protecting the heart comes before shifting or removing potassium.
Why the other options are wrong
- A. A binder removes potassium through the gut but takes hours to work.
- C. Insulin with dextrose shifts potassium into cells within 15 to 30 minutes, which is second, not first, once ECG changes are present.
- D. Dialysis definitively removes potassium but takes time to arrange and initiate.
A monitored client suddenly becomes unresponsive. The monitor shows a chaotic waveform with no organised complexes, and no pulse is palpable. Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Begin chest compressions and call for the defibrillator
A chaotic waveform without a pulse is ventricular fibrillation. Immediate high-quality compressions maintain perfusion while defibrillation is prepared, and early defibrillation is the definitive treatment.
Why the other options are wrong
- A. Epinephrine is given during resuscitation but does not precede compressions and defibrillation.
- C. Obtaining a 12-lead in a pulseless client wastes the minutes that determine survival.
- D. Synchronised cardioversion requires an organised rhythm to synchronise with, which ventricular fibrillation does not have.
A client admitted with an asthma exacerbation was audibly wheezing on arrival. Thirty minutes later the wheezing has stopped, the respiratory rate is 34 and the client can no longer speak in full sentences. Which interpretation is correct?
Show answer and rationale
Correct answer: B. Airflow has become severely limited and the client is deteriorating
Wheezing requires air movement. Disappearance of wheeze with worsening work of breathing and inability to speak means airflow has fallen so far that sound is no longer produced. This is a silent chest and signals impending respiratory failure.
Why the other options are wrong
- A. Improvement would come with a falling respiratory rate, easier speech and better saturation, not with rising distress.
- C. Pneumothorax produces unilateral absent breath sounds with sudden pleuritic pain, not a symmetrical silent chest.
- D. Anxiety does not abolish wheezing in an active exacerbation.
A client with a chest tube suddenly develops severe dyspnoea, absent breath sounds on the right, tracheal deviation to the left, and a blood pressure of 84/50 mmHg. Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Call for immediate assistance and prepare for emergency decompression
Tracheal deviation away from the affected side with absent breath sounds and hypotension describes a tension pneumothorax. Pressure is compressing the heart and great vessels, and immediate decompression is required.
Why the other options are wrong
- A. Clamping traps air in the pleural space and converts a manageable situation into a worse tension pneumothorax.
- C. Lying flat worsens the respiratory compromise and does not address the cause of the hypotension.
- D. Milking or stripping a chest tube generates dangerous negative pressure and is not done.
A client with a T4 spinal cord injury reports a pounding headache. Blood pressure is 208/112 mmHg and the face is flushed. Place the nursing actions in order, from first to last.
- ARaise the head of the bed to a sitting position
- BCheck for a kinked urinary catheter or distended bladder
- CLoosen tight clothing and check for a bowel impaction
- DNotify the provider and prepare to give a prescribed antihypertensive
Show answer and rationale
Correct order: 1) A. Raise the head of the bed to a sitting position 2) B. Check for a kinked urinary catheter or distended bladder 3) C. Loosen tight clothing and check for a bowel impaction 4) D. Notify the provider and prepare to give a prescribed antihypertensive
Sitting the client up uses gravity to lower blood pressure immediately and takes seconds. The most common trigger is a distended bladder, so that is checked next, then other triggers, then pharmacological control if the pressure remains dangerously high.
A client with diabetic ketoacidosis is receiving an intravenous insulin infusion. The glucose has fallen from 520 to 260 mg/dL and the potassium is 3.4 mEq/L. Which action should the nurse anticipate?
Show answer and rationale
Correct answer: B. Adding potassium to the intravenous fluids as prescribed
Insulin drives potassium into cells along with glucose. Even a client who started with a normal or high potassium will drop as treatment progresses, so potassium is replaced as the level falls to keep it in a safe range.
Why the other options are wrong
- A. The insulin infusion continues until the anion gap closes; stopping early allows ketosis to persist.
- C. A dextrose bolus is for hypoglycaemia. Here dextrose is typically added to the fluids once glucose falls near 200, not given as a bolus.
- D. Clients in ketoacidosis are profoundly volume depleted and need fluid replacement.
Six hours after a total thyroidectomy, a client reports numbness and tingling around the mouth and in the fingertips. Which action should the nurse take?
Show answer and rationale
Correct answer: B. Notify the provider, as this may indicate hypocalcaemia from parathyroid injury
The parathyroid glands sit on the posterior thyroid and can be injured or removed during thyroidectomy. Perioral and fingertip paraesthesia is an early sign of hypocalcaemia, which can progress to tetany, laryngospasm and seizures.
Why the other options are wrong
- A. This finding is not an expected part of recovery and delaying treatment risks tetany.
- C. Rebreathing is used for hyperventilation-induced respiratory alkalosis, which worsens rather than treats hypocalcaemic tetany.
- D. A warm compress does nothing for a serum calcium problem.
A client with a cervical spinal cord injury has a blood pressure of 82/48 mmHg, a heart rate of 48 beats per minute, and warm dry skin. Which type of shock does this most likely represent?
Show answer and rationale
Correct answer: C. Neurogenic shock
Neurogenic shock follows loss of sympathetic tone after a high spinal cord injury. It is the one shock state that produces bradycardia with hypotension, and the skin stays warm and dry because vasoconstriction is lost.
Why the other options are wrong
- A. Hypovolaemic shock produces tachycardia with cool clammy skin.
- B. Cardiogenic shock produces tachycardia with cool skin and signs of pulmonary congestion.
- D. Early septic shock produces warm skin but with tachycardia and usually fever.
What to do with your score
A single 27-item set is too short to predict a pass, so treat the number as a pointer rather than a verdict. What is worth acting on is the pattern: go back through every item you missed, and write down whether you lacked the fact, misread what the item asked for, or knew the fact and still picked second-best. Those three failures need three different fixes — more content review, slower reading, or priority-framework drilling.
Read the rationale on the items you got right too. On a well-written item you can arrive at the correct option for the wrong reason, and that will not survive a harder version of the same question.
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