NCLEX-RN
Physiological Adaptation NCLEX RN Questions
Question 1 of 5
The nurse is caring for a client who just returned from a right mastectomy. Which position does the nurse anticipate for the client?
Correct Answer: C
Rationale: Semi-Fowler's with the affected arm supported (
C) promotes comfort and reduces lymphedema risk post-mastectomy. High Fowler's (
A), flat (
B), and reverse Trendelenburg's (
D) are less optimal.
Question 2 of 5
The nurse is caring for a client with a Braden score of 13. How does the nurse interpret this client's risk of skin breakdown?
Correct Answer: A
Rationale: A Braden score of 13 indicates high risk (
A) for skin breakdown (scores ≤14). Mild (
B), severe (
C), and moderate (
D) do not align with standard Braden scale interpretations.
Question 3 of 5
A client with third- and fourth-degree burns is in the burn unit. The nurse understands that which of the following is true regarding fluid shift in burn clients?
Correct Answer: D
Rationale: Burns cause fluid leakage, leading to severe edema even in unburned areas (
D). Hyperkalemia (not hypokalemia,
A), increased viscosity (
B), and weight gain (not loss,
C) occur.
Question 4 of 5
The nurse is preparing to extubate a client. Arrange in order of priority the actions that the nurse should take to perform this procedure.
Order the Items
Source Container
Correct Answer: B,F,A,E,G,C,D
Rationale: Explain procedure (
B) to prepare client,(F) set up oxygen/emergency equipment , hyperoxygenate (
A), suction (E), deflate cuff/remove tube (G), instruct to cough (
C), apply oxygen (
D), teach spirometer use
Question 5 of 5
The nurse is assessing a client with Graves' disease. Which assessment finding would the nurse expect in this client?
Correct Answer: C
Rationale: Graves' disease, a form of hyperthyroidism, causes exophthalmos (
C) due to orbital tissue inflammation. Bradycardia (
A), constipation (
B), and weight gain (
D) are associated with hypothyroidism.