Physiological Adaptation — NCLEX-RN practice questions

Using the primary survey (ABCDE) in trauma assessment, which finding takes priority?

1. A closed, non-displaced wrist fracture with intact distal pulses
2. A 2 cm scalp laceration with minimal bleeding controlled by pressure
3. Stridor and inability to speak in a client with facial trauma
4. Bruising over the flank with tenderness reported on palpation

Answer: C — Stridor and inability to speak in a client with facial trauma

C) Correct — airway compromise is first in the primary survey and immediately life-threatening. A) A lower priority, addressed later. B) Minor bleeding is not immediately life-threatening. D) Requires assessment but isn't immediate.

A nurse is caring for an infant with pyloric stenosis. Which finding should the nurse report immediately?

1. A weight loss of about 2% since admission with a flat, soft fontanel
2. Sunken fontanel, decreased urine output, and lethargy with vomiting after every feeding
3. Slightly dry lips with moist oral mucosa and brisk capillary refill time
4. Mild fussiness before feedings that settles as soon as the feeding begins

Answer: B — Sunken fontanel, decreased urine output, and lethargy with vomiting after every feeding

B) Correct — signs of significant dehydration/hypochloremic metabolic alkalosis from persistent vomiting require prompt IV fluid and electrolyte correction before surgical repair. A) A minor weight change alone isn't the priority finding. C) A mild finding to monitor. D) Expected hunger-related fussiness.

The nurse receives report on four clients. Which client requires the MOST IMMEDIATE intervention?

1. A client with a potassium of 2.9 mEq/L on telemetry showing frequent PVCs
2. A client with a sodium of 128 mEq/L who is alert, oriented, and without headache
3. A client with a hemoglobin of 8.2 g/dL who is asymptomatic and hemodynamically stable
4. A client with a fasting glucose of 188 mg/dL who is awaiting the morning insulin dose

Answer: A — A client with a potassium of 2.9 mEq/L on telemetry showing frequent PVCs

A) Correct: hypokalemia + PVCs is pre-arrest — potassium must be repleted urgently and the rhythm watched. B) Mild hyponatremia without neurologic symptoms is not immediately life-threatening. C) Mild anemia without symptoms can be addressed without urgency. D) Hyperglycemia at this level is not an emergency.

Which findings help differentiate diabetic ketoacidosis (DKA) from hyperosmolar hyperglycemic state (HHS)?

1. DKA typically involves significant ketosis/acidosis with Kussmaul respirations; HHS involves extremely high glucose with minimal ketosis and profound dehydration/altered mental status
2. DKA occurs only in type 2 diabetes and is triggered by infection, whereas HHS occurs only in type 1 diabetes and is triggered by missed insulin doses
3. Both conditions produce identical glucose, ketone, and serum osmolality profiles, so only the client's age and documented diabetes type can distinguish them at the bedside
4. HHS always presents with a fruity breath odor and deep Kussmaul respirations, while DKA is marked by profound dehydration with minimal acidosis

Answer: A — DKA typically involves significant ketosis/acidosis with Kussmaul respirations; HHS involves extremely high glucose with minimal ketosis and profound dehydration/altered mental status

A) Correct — DKA (usually type 1) features significant ketoacidosis with compensatory Kussmaul breathing; HHS (usually type 2) features extreme hyperglycemia with minimal ketosis and often more profound neurologic changes from dehydration/hyperosmolarity. B) Reversed — DKA is more typical of type 1, HHS of type 2, though overlap exists. C) The two conditions have distinct profiles. D) Fruity (ketotic) breath is characteristic of DKA, not HHS.

A patient is admitted with COPD exacerbation and pH 7.30, PaCO₂ 60, HCO₃ 30. This represents:

1. Metabolic acidosis with respiratory compensation
2. Respiratory acidosis with partial compensation
3. Respiratory alkalosis with metabolic compensation
4. Mixed metabolic and respiratory disturbance

Answer: B — Respiratory acidosis with partial compensation

pH < 7.35 = acidosis. PaCO₂ > 45 = respiratory cause. HCO₃ > 26 = renal compensation kicking in. This is respiratory acidosis with partial metabolic compensation, classic for chronic CO₂ retention in COPD.

Which finding would the nurse recognize as a sign of increased intracranial pressure in an infant, distinct from an older child?

1. A bulging fontanel and widening suture lines with a high-pitched cry
2. Cushing's triad of bradycardia, hypertension, and irregular respirations as the earliest reliable sign
3. A sunken fontanel with overriding cranial sutures as the skull decompresses the rising pressure
4. Head circumference tracking steadily along the same growth percentile, which rules out rising pressure

Answer: A — A bulging fontanel and widening suture lines with a high-pitched cry

A) Correct — infants can compensate for rising ICP via open fontanels/sutures, presenting with a bulging fontanel, widening sutures, and a high-pitched cry before classic adult signs appear. B) Cushing's triad is a late finding in infants; the compensatory cranial signs appear well before it. C) A sunken fontanel with overriding sutures suggests dehydration or volume depletion, not rising intracranial pressure. D) Rapidly increasing head circumference would actually be concerning for ICP/hydrocephalus, and stable growth does not rule it out.

Which nursing interventions are appropriate for a client immediately following an ST-elevation myocardial infarction (STEMI) and successful PCI? SELECT ALL THAT APPLY.

1. Continuous cardiac monitoring
2. Monitor the femoral or radial access site for bleeding/hematoma
3. Administer dual antiplatelet therapy as prescribed
4. Encourage immediate strenuous exercise to test cardiac function
5. Monitor for signs of reocclusion (recurrent chest pain, ST changes)
6. F) Educate on risk factor modification (smoking cessation, diet, activity)

Answer: ABCEF

Correct: A, B, C, E, F. These reflect standard post-PCI monitoring and secondary prevention teaching. D) Wrong — strenuous exercise immediately post-MI/PCI is contraindicated; activity is progressed gradually per cardiac rehab protocol.

A patient with type 1 diabetes presents with fruity breath, deep rapid breathing, and serum glucose 480 mg/dL. The MOST likely diagnosis:

1. Hypoglycemia
2. Hyperosmolar hyperglycemic state without ketoacidosis
3. Diabetic ketoacidosis (DKA)
4. Normal glucose variability

Answer: C — Diabetic ketoacidosis (DKA)

DKA: hyperglycemia + ketosis + acidosis. Kussmaul respirations (deep, rapid) blow off CO2 to compensate. Fruity breath = acetone. Treat: fluids, insulin infusion, K+ replacement, identify precipitating cause.

Normal arterial pH?

7.35-7.45. Below = acidosis. Above = alkalosis.

Heart failure left vs right?

Left: pulmonary congestion (crackles, dyspnea). Right: peripheral edema, JVD, ascites.

Bowel obstruction signs?

Abdominal distension, absent or high-pitched bowel sounds, vomiting (may be feculent if low obstruction), obstipation.

PEA / asystole?

CPR + epinephrine. Don't shock asystole or PEA.