NCLEX-RN
Physiological Adaptation NCLEX RN Questions
Extract:
Question 1 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 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 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 5 of 5
The ED nurse has admitted a client who is homeless and was found unresponsive in the street during below freezing temperatures. The client is diagnosed with severe hypothermia. The nurse should implement which measures for this client? Select all that apply.
Correct Answer: A,C,D,F
Rationale: Heating blanket (
A), assessing consciousness (
C), supine position (
D), and preparing for CPR (F) are appropriate for severe hypothermia. Oral temperature (
B) is inaccurate, and vigorous massage (E) risks tissue damage.