NCLEX-PN Physiological Adaptation Practice Questions

Managing acute and chronic conditions — shock, sepsis, stroke, MI, and physiological crises — at the PN level. It sits under Physiological Integrity on the NCLEX-PN test plan and carries an approximate weight of 10% of the exam.

Below are 12 practice questions for this domain — 8 multiple-choice and 4 select-all-that-apply. Every item gives a rationale for each option, not just the correct one: on the NCLEX-PN 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 Multiple choice

1. Hypoglycemia in a conscious client

A nurse checks the blood glucose of an alert, oriented client with type 1 diabetes who reports feeling shaky and sweaty. The point-of-care reading is 58 mg/dL, and the client is able to swallow safely.

Which action should the nurse take first?

  1. Give 15 grams of a fast-acting carbohydrate, such as 4 ounces of fruit juice.
  2. Administer the client's next scheduled dose of subcutaneous insulin.
  3. Offer the client a turkey sandwich and a glass of milk.
  4. Prepare to give intramuscular glucagon.
Show the answer and rationales

Correct answer: A

  • A. Correct . For a conscious client who can swallow, the 15-15 rule applies — give 15 grams of fast-acting carbohydrate, wait 15 minutes, then recheck the glucose. This is the priority for a value below 70 mg/dL.
  • B. Incorrect . Insulin lowers blood glucose and would deepen the hypoglycemia. Insulin is the treatment for hyperglycemia, not low blood sugar.
  • C. Incorrect . Protein and fat slow carbohydrate absorption, so a sandwich does not raise glucose quickly enough during an active low. A complex snack may follow once the glucose is back in range.
  • D. Incorrect . Glucagon is reserved for a client who is unconscious or unable to swallow safely. This client is alert and can take oral carbohydrate, so glucagon is not indicated.

Reference: CDC (treatment of low blood sugar); American Diabetes Association hypoglycemia guidance

Easy Multiple choice

2. Hypoglycemia in an alert client — first action

A client with type 1 diabetes who received insulin before breakfast reports feeling shaky and weak at 1000. The nurse notes cool, clammy skin, and the fingerstick blood glucose is 54 mg/dL. The client is awake, alert, and able to swallow.

Which action should the nurse take first?

  1. Give the client 4 ounces of fruit juice.
  2. Give the client a snack of peanut butter and crackers.
  3. Administer the client's scheduled mealtime insulin.
  4. Recheck the blood glucose in 30 minutes before treating.
Show the answer and rationales

Correct answer: A

  • A. Correct . A blood glucose below 70 mg/dL with shakiness and cool, clammy skin is hypoglycemia. A conscious client who can swallow receives 15 grams of fast-acting carbohydrate — such as 4 ounces of juice — and the glucose is rechecked in 15 minutes per the 15-15 rule.
  • B. Incorrect . Protein and fat slow glucose absorption. A complex snack is appropriate after the glucose has risen, to prevent recurrence — not as the initial treatment of an active low.
  • C. Incorrect . Insulin lowers blood glucose further and could push the client into a seizure or loss of consciousness. Insulin is withheld and the episode reported.
  • D. Incorrect . Symptomatic hypoglycemia requires immediate treatment. The recheck in the 15-15 rule happens 15 minutes after carbohydrate is given, not before treatment.

Reference: American Diabetes Association and CDC hypoglycemia treatment guidance (15-15 rule)

Easy Select all that apply

3. Pneumonia — supportive interventions

A nurse is reinforcing the plan of care for an older adult client admitted with community-acquired pneumonia. The client has a productive cough, a temperature of 38.4 C (101.1 F), and an SpO2 of 92 percent on room air.

Which interventions are appropriate for the nurse to include? Select all that apply.

  1. Elevate the head of the bed to a semi-Fowler or high-Fowler position.
  2. Encourage coughing, deep breathing, and use of the incentive spirometer.
  3. Encourage increased fluid intake unless contraindicated.
  4. Monitor the client for new or increasing confusion.
  5. Keep the client flat in bed and limit position changes to conserve energy.
  6. Restrict fluids to less than 1000 mL per day to reduce coughing.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Raising the head of the bed eases the work of breathing and promotes lung expansion and secretion clearance.
  • B. Correct . These measures expand the alveoli and help mobilize and expel secretions, improving gas exchange.
  • C. Correct . Adequate hydration thins secretions so they are easier to cough up. Fluids are encouraged unless heart or kidney conditions limit them.
  • D. Correct . In older adults, worsening confusion can be an early sign of increasing hypoxia and should be reported.
  • E. Incorrect . Lying flat reduces lung expansion and pools secretions, worsening breathing. Repositioning and upright posture are encouraged.
  • F. Incorrect . Restricting fluids thickens secretions and makes them harder to clear. Fluid restriction is not indicated for pneumonia unless another condition requires it.

Reference: MedlinePlus (pneumonia); standard nursing care guidance for pneumonia

Easy Select all that apply

4. Tonic-clonic seizure — nursing actions

A nurse is in the room when a client with a known seizure disorder begins having a generalized tonic-clonic seizure in bed.

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

  1. Turn the client onto the side.
  2. Place a soft pad or folded blanket under the client's head.
  3. Loosen tight clothing around the client's neck.
  4. Note the time the seizure starts and observe the type of movements.
  5. Insert a padded tongue blade between the client's teeth.
  6. Hold the client's arms and legs still until the movements stop.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Side-lying lets saliva drain out of the mouth and helps keep the airway clear during the seizure and the postictal period.
  • B. Correct . Padding under the head protects it from injury while the involuntary movements continue.
  • C. Correct . Loosening anything restrictive around the neck keeps it from interfering with breathing.
  • D. Correct . A seizure lasting more than 5 minutes is a medical emergency, so timing is essential, and an accurate description of onset, duration, and activity must be reported and documented.
  • E. Incorrect . Never put anything in the mouth during a seizure — it can break teeth, injure the gums, or obstruct the airway. A person cannot swallow the tongue during a seizure.
  • F. Incorrect . Restraining a seizing client can cause musculoskeletal injury. Instead, clear hard or sharp objects away and let the movements run their course.

Reference: CDC seizure first aid guidance; Epilepsy Foundation

Medium Multiple choice

5. Acute stroke — preventing aspiration

A nurse is helping care for a client admitted with a suspected acute ischemic stroke. The client has facial drooping and slurred speech, and a swallow screen has not yet been completed. A family member brings in the client's favorite coffee and asks the nurse to give it to the client.

Which action by the nurse is most appropriate?

  1. Keep the client NPO and explain that a swallow screen is needed before any food or drink.
  2. Give the coffee slowly while the client is sitting fully upright.
  3. Thicken the coffee with a commercial thickener before offering it.
  4. Allow only small sips of water to test whether the client can swallow.
Show the answer and rationales

Correct answer: A

  • A. Correct . Clients with acute stroke are kept NPO until a swallow screen is passed, because dysphagia raises the risk of aspiration and pneumonia. Reinforcing this with the family is correct and within PN scope.
  • B. Incorrect . Upright positioning helps, but any oral intake before a documented swallow screen risks aspiration in a client with new slurred speech and facial droop.
  • C. Incorrect . Thickened liquids may be ordered after a swallow evaluation, but the PN does not start a modified diet on a client who has not yet been screened.
  • D. Incorrect . Performing an informal swallow test exceeds the situation; the client must remain NPO until a screen is done by qualified staff per protocol.

Reference: 2026 AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke

Medium Select all that apply

6. Casted extremity — findings to report

A nurse is collecting data on a client who had a long-leg cast applied 6 hours ago for a tibial fracture. The client is now reporting increasing pain in the casted leg.

Which findings should the nurse report to the registered nurse immediately? Select all that apply.

  1. Deep, throbbing pain that is not relieved by the prescribed analgesic.
  2. Numbness and tingling in the toes of the casted leg.
  3. Toes that are pale and cool with sluggish capillary refill.
  4. Severe pain when the toes are passively stretched or moved.
  5. Mild itching of the skin along the edge of the cast.
  6. Warm, pink toes that move freely on request.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Pain out of proportion to the injury and unrelieved by analgesics is the earliest red flag for acute compartment syndrome, a limb-threatening emergency.
  • B. Correct . Paresthesia signals nerve compromise from rising compartment pressure and must be reported without delay.
  • C. Correct . Pallor, coolness, and delayed capillary refill point to impaired circulation (ischemia) distal to the injury and require urgent evaluation.
  • D. Correct . Pain on passive stretch of the muscles in the compartment is a classic early sign of compartment syndrome and should be escalated promptly.
  • E. Incorrect . Itching under or around a new cast is common and is not an emergency. The client should be discouraged from inserting objects to scratch.
  • F. Incorrect . Warm, pink, mobile toes are a normal neurovascular finding and indicate adequate circulation, not a complication.

Reference: OrthoInfo (American Academy of Orthopaedic Surgeons) on compartment syndrome; StatPearls (acute compartment syndrome)

Medium Multiple choice

7. Chest pain — before nitroglycerin

A client on a telemetry unit reports crushing substernal chest pain rated 8 out of 10 with nausea and diaphoresis. There is a standing order for sublingual nitroglycerin for chest pain. The nurse is preparing to reinforce the plan of care.

Which action should the nurse take before giving a sublingual nitroglycerin tablet?

  1. Check the client's blood pressure.
  2. Apply high-flow oxygen by non-rebreather mask.
  3. Have the client lie flat and elevate both legs.
  4. Encourage the client to take slow, deep breaths to relieve the pain.
Show the answer and rationales

Correct answer: A

  • A. Correct . Nitroglycerin dilates vessels and lowers blood pressure, so it is held when the systolic pressure is below 90 mmHg. Checking the blood pressure before each dose is an essential safety step.
  • B. Incorrect . Routine high-flow oxygen is no longer recommended for chest pain; oxygen is given only if the client is hypoxic. Current guidance retired the old practice of giving oxygen to everyone with chest pain.
  • C. Incorrect . Lying flat does not address the medication safety check and may worsen breathing. Position is not the priority before a vasodilator that can drop blood pressure.
  • D. Incorrect . Breathing techniques will not relieve ischemic cardiac pain and delay the needed assessment. The blood pressure check must come first.

Reference: FDA prescribing information (nitroglycerin sublingual); 2020 AHA ACLS / acute coronary syndrome oxygen guidance

Medium Multiple choice

8. Diabetes with vomiting — finding to report

A nurse is collecting data on a client with type 1 diabetes who has been vomiting for 2 days and admits to skipping several insulin doses while unable to eat.

Which finding should the nurse report to the RN immediately?

  1. Deep, rapid respirations and a fruity odor to the breath.
  2. Reports of increased thirst over the past 2 days.
  3. Dry, cracked lips and dry mucous membranes.
  4. Urine output of 250 mL over the past 4 hours.
Show the answer and rationales

Correct answer: A

  • A. Correct . Kussmaul respirations with a fruity (acetone) breath odor signal diabetic ketoacidosis — the lungs are blowing off carbon dioxide to compensate for metabolic acidosis. DKA is life-threatening and must be reported immediately so insulin and fluid therapy can begin.
  • B. Incorrect . Polydipsia reflects hyperglycemia and should be documented and followed up, but by itself it is an expected early finding, not the immediately life-threatening one.
  • C. Incorrect . These indicate dehydration from vomiting and need attention, but they are less urgent than the respiratory signs of acidosis.
  • D. Incorrect . This is roughly 60 mL/hr, an adequate urine output that does not require urgent reporting.

Reference: NCBI StatPearls (Adult Diabetic Ketoacidosis); American Academy of Family Physicians DKA review

Medium Multiple choice

9. Heart failure — change to report

A nurse is reviewing the daily weights of four clients with heart failure on a medical unit. All weights were taken on the same scale at the same time each morning.

Which finding should the nurse report to the registered nurse first?

  1. A client who gained 3 pounds since yesterday and now has new shortness of breath.
  2. A client whose weight is unchanged from the previous morning.
  3. A client who lost 1 pound after a dose of a prescribed diuretic.
  4. A client with mild ankle edema that is unchanged from the day before.
Show the answer and rationales

Correct answer: A

  • A. Correct . A gain of more than 2 to 3 pounds in a day, especially with new dyspnea, signals worsening fluid overload and possible decompensation. This client needs prompt evaluation and is reported first.
  • B. Incorrect . A stable weight suggests fluid status is being maintained. There is no acute change to report.
  • C. Incorrect . Gentle, expected diuresis after a diuretic is a desired response, not a red flag. This client is improving.
  • D. Incorrect . Chronic, stable ankle edema is expected in heart failure and is not the priority. Daily weight is a more sensitive measure of fluid change than visible swelling.

Reference: American Heart Association (managing heart failure symptoms); MedlinePlus (heart failure - fluids and diuretics)

Medium Multiple choice

10. Sudden postoperative dyspnea — first action

A nurse is collecting data on a client who is 2 days postoperative following total hip arthroplasty. The client suddenly reports sharp chest pain and shortness of breath. The nurse notes respirations 32/min, heart rate 118/min, and SpO2 88% on room air. The client appears anxious and restless.

Which action should the nurse take first?

  1. Raise the head of the bed and apply oxygen according to the facility protocol.
  2. Assist the client to ambulate in the hallway to improve lung expansion.
  3. Lower the head of the bed flat and elevate the client's legs.
  4. Recheck the vital signs in 15 minutes and document the findings.
Show the answer and rationales

Correct answer: A

  • A. Correct . Sudden dyspnea, chest pain, tachycardia, and hypoxemia in a postoperative client suggest a pulmonary embolism. Sitting the client upright and applying oxygen addresses the oxygenation emergency immediately; the nurse then reports the findings to the RN and provider right away.
  • B. Incorrect . Early ambulation helps prevent venous thromboembolism, but once an embolism is suspected, activity increases oxygen demand and could dislodge additional clot. The client should remain in bed.
  • C. Incorrect . This position is used for some hypotensive states, but lying flat increases the work of breathing and worsens dyspnea. A client with suspected pulmonary embolism is positioned upright.
  • D. Incorrect . A suspected pulmonary embolism is a life-threatening emergency. Waiting to recheck delays oxygenation and provider notification when every minute matters.

Reference: MedlinePlus (pulmonary embolus); standard nursing care guidance for suspected pulmonary embolism

Hard Select all that apply

11. Diabetic ketoacidosis — findings to report

A nurse is collecting data on a client with type 1 diabetes who reports several days of nausea and increased urination. The blood glucose reads HIGH on the glucometer. The nurse gathers additional findings to report to the registered nurse.

Which findings are consistent with diabetic ketoacidosis and should be reported? Select all that apply.

  1. Deep, rapid Kussmaul respirations.
  2. A fruity or acetone odor to the client's breath.
  3. Dry mucous membranes and poor skin turgor.
  4. Reports of excessive thirst and frequent urination.
  5. Cool, clammy skin with diaphoresis.
  6. A slow, deep sleep with no respiratory effort changes.
Show the answer and rationales

Correct answers: A, B, C, D

  • A. Correct . Kussmaul respirations are the lungs blowing off carbon dioxide to compensate for metabolic acidosis, a hallmark of DKA.
  • B. Correct . A fruity breath odor reflects the ketones produced when the body burns fat for fuel without enough insulin.
  • C. Correct . The osmotic diuresis of high glucose causes profound dehydration, seen as dry membranes and decreased skin turgor.
  • D. Correct . Polydipsia and polyuria are classic effects of hyperglycemia and a common lead-in to DKA.
  • E. Incorrect . Cold, clammy, sweaty skin points to hypoglycemia, the opposite emergency. Hyperglycemia and DKA typically present with warm, dry skin.
  • F. Incorrect . DKA increases the rate and depth of breathing (Kussmaul respirations); unchanged, effortless breathing is not consistent with the acidosis of DKA.

Reference: MedlinePlus (diabetic ketoacidosis); StatPearls (adult diabetic ketoacidosis)

Hard Multiple choice

12. Early sepsis — recognizing the change

A nurse is collecting data on an older adult client who is 3 days postoperative after abdominal surgery. The client was alert this morning but is now confused and difficult to arouse. Vital signs are temperature 38.6 C (101.5 F), heart rate 116/min, respirations 24/min, and blood pressure 98/56 mmHg. The surgical dressing is saturated with foul-smelling drainage.

Which action should the nurse take first?

  1. Report the change in level of consciousness and vital signs to the registered nurse immediately.
  2. Change the saturated surgical dressing using sterile technique.
  3. Encourage the client to drink extra oral fluids to support blood pressure.
  4. Apply a cooling blanket to bring down the client's temperature.
Show the answer and rationales

Correct answer: A

  • A. Correct . New confusion with fever, tachycardia, tachypnea, and a dropping blood pressure in a postoperative client signals possible sepsis progressing toward septic shock. Rapid escalation to the RN is the priority so cultures, fluids, and antibiotics can be started without delay.
  • B. Incorrect . Reinforcing or changing the dressing may be done, but it does not address the life-threatening systemic deterioration. Recognition and escalation come first.
  • C. Incorrect . A confused, difficult-to-arouse client cannot safely take oral fluids and may aspirate. Resuscitation in sepsis is provider-directed IV fluid, not oral intake.
  • D. Incorrect . Treating only the fever ignores the urgent perfusion problem and delays definitive care. The systemic decline must be reported right away.

Reference: Surviving Sepsis Campaign guidelines; CDC sepsis recognition guidance

Keep practising

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