Free NCLEX-RN Physiological Adaptation Questions
Free NCLEX-RN physiological adaptation practice questions with rationales — managing acute, unstable, and chronic conditions.
A client in the active phase of labor has weak contractions every 7 to 10 minutes, and cervical dilation has not changed for 3 hours. The fetal heart rate is reassuring and the provider has ruled out cephalopelvic disproportion. Which intervention does the nurse anticipate?
Correct answer: A
When contractions are weak and infrequent (hypotonic dysfunction) and disproportion has been ruled out, the goal is to strengthen the pattern, so oxytocin augmentation, commonly paired with amniotomy, is anticipated. Position changes and ambulation are supportive but will not correct an established hypotonic pattern that has stalled dilation for hours; amniotomy by itself may not generate adequate contractions and is typically combined with oxytocin; and a tocolytic would relax the uterus further and worsen the inadequate labor.
Why the other options are wrong
- B. Position changes and walking are useful to encourage fetal descent in early labor or mild stalling. Key distinction: Active phase hypotonic arrest that has persisted for three hours requires pharmacological or surgical stimulation rather than positional adjustments alone.
- C. Artificial rupture of membranes releases local prostaglandins and may increase contraction strength slightly. Key distinction: In established hypotonic dysfunction, amniotomy alone is rarely sufficient to restore progress and is typically paired with an oxytocin infusion.
- D. Tocolytic agents (like terbutaline) are administered to stop contractions in cases of preterm labor or uterine tachysystole. Key distinction: Giving a tocolytic to a client with already weak and infrequent contractions would completely halt labor and worsen the hypotonic state.
Key takeaway: Hypotonic labor with disproportion ruled out is managed by augmenting contractions (oxytocin, often with amniotomy).
A client develops severe dyspnea and hypoxemia that does not improve with high-flow oxygen, and the chest x-ray shows diffuse bilateral infiltrates with a normal heart size. What does the nurse anticipate?
Correct answer: A
Hypoxemia that does not respond to high-flow oxygen, with diffuse bilateral infiltrates and a normal heart size, is acute respiratory distress syndrome — non-cardiogenic pulmonary edema. Because the shunt no longer responds to supplemental oxygen, more oxygen by mask (non-rebreather) will not fix it, and BiPAP with a delayed reassessment is unsafe for refractory, progressing hypoxemia. The normal heart size points away from cardiogenic overload, so furosemide is not the answer. ARDS is managed with intubation and mechanical ventilation using positive end-expiratory pressure (PEEP) to recruit collapsed alveoli.
Why the other options are wrong
- B. The hypoxemia is already refractory to high-flow oxygen; a non-rebreather adds oxygen the failing shunt cannot use.
- C. BiPAP plus an hour of watchful waiting is unsafe when hypoxemia is refractory and worsening; ARDS usually needs intubation.
- D. A normal heart size makes cardiogenic overload unlikely, so diuresis and a bronchodilator do not treat the ARDS.
Key takeaway: Refractory hypoxemia + diffuse bilateral infiltrates + normal heart size is ARDS (non-cardiogenic): anticipate intubation and mechanical ventilation with PEEP, not more oxygen or diuresis.
Which finding should the nurse recognize as a sign of peripheral ARTERIAL disease rather than venous insufficiency?
Correct answer: B
Arterial disease reduces blood flow to the tissues, so it causes intermittent claudication (leg pain with walking that eases with rest), cool pale extremities, diminished or absent pulses, and pain that worsens with elevation. Warm legs, brownish ankle discoloration, edema that improves with elevation, and ankle ulcers are signs of venous insufficiency.
Why the other options are wrong
- A. Warmth and brownish ankle pigmentation (hemosiderin staining) stem from chronic venous stasis and erythrocyte extravasation. Key distinction: Venous insufficiency causes warm, hyperpigmented skin; arterial insufficiency causes cool, pale, or ruborous skin.
- C. Edema that decreases with elevation occurs because gravity facilitates venous return through incompetent veins. Key distinction: Leg elevation relieves venous edema but accentuates arterial ischemic pain by decreasing arterial perfusion pressure.
- D. Medial malleolus ulcers with irregular borders and wet exudate stem from venous hypertension. Key distinction: Venous ulcers occur at the ankle with moist bases, whereas arterial ulcers occur on toes or heels with clean, pale, dry bases.
Key takeaway: Arterial disease: claudication, cool pale limb, diminished pulses, pain worse with elevation. Venous: warmth, ankle discoloration, edema relieved by elevation.
A client at 7 weeks of pregnancy reports sudden sharp one-sided lower abdominal pain, and now has shoulder pain, dizziness, and a blood pressure of 88/54 mm Hg. Which does the nurse suspect?
Correct answer: C
Sudden one-sided pelvic pain early in pregnancy with shoulder pain (from blood irritating the diaphragm), dizziness, and a falling blood pressure points to a ruptured ectopic pregnancy with internal bleeding, a surgical emergency. Round ligament pain and a urinary infection do not cause hypotension, and Braxton Hicks contractions do not occur this early.
Why the other options are wrong
- A. Round ligament pain is a sharp, stretching pain felt in the lower abdomen or groin during the second trimester as the uterus expands. It does not cause shoulder pain, dizziness, or hypotension, which are signs of internal hemorrhage. Key distinction: Round ligament pain is a physiological discomfort, whereas ruptured ectopic pregnancy is a life-threatening emergency.
- B. A urinary tract infection presents with dysuria, frequency, urgency, and occasionally suprapubic pain or low-grade fever. It does not cause sudden, severe one-sided pelvic pain, referred shoulder pain, or shock. Key distinction: Urinary tract infections do not cause intra-abdominal bleeding or cardiovascular collapse.
- D. Braxton Hicks contractions are irregular, painless uterine tightenings that typically occur in the second or third trimester. They do not occur at 7 weeks of gestation and do not cause severe pain or hypotension. Key distinction: Braxton Hicks contractions are mild and localized to the uterus, while ectopic rupture is painful and causes systemic shock.
Key takeaway: Ruptured ectopic pregnancy: sudden one-sided pain, referred shoulder pain, and hypotension early in pregnancy.
One hour after a vaginal birth, the nurse finds the client's uterus soft and boggy and above the level of the umbilicus, with a large amount of vaginal bleeding. Which is the first action?
Correct answer: D
A soft, boggy uterus with heavy bleeding means uterine atony, the leading cause of early postpartum hemorrhage. The first action is to massage the fundus until it contracts and becomes firm, which slows the bleeding. Emptying the bladder, notifying the provider, and giving fluids may follow, but firm massage comes first because it directly stops the loss.
Why the other options are wrong
- A. A full bladder can displace the uterus and prevent it from contracting, but performing catheterization first is incorrect because it delays the direct manual compression needed to slow the active bleeding. Massage the fundus to control hemorrhage first, then address the bladder. Key distinction: Fundal massage directly stops the bleeding, while catheterization is a secondary step to resolve the underlying cause of bladder distention.
- B. Notifying the provider is necessary, but waiting for orders delays essential, immediate care. Fundal massage is a nursing action that must be initiated immediately to prevent severe hypovolemia. Key distinction: Delaying massage to obtain orders is unsafe because postpartum hemorrhage can cause rapid death.
- C. Increasing the IV fluid rate replaces circulating volume but does not address the source of the bleeding. The uterine muscle must contract to stop the blood loss. Key distinction: Volume resuscitation supports blood pressure but does not stop the hemorrhage.
Key takeaway: Boggy uterus with heavy bleeding: massage the fundus first until firm.
The nurse finds a postpartum client with a boggy uterus and heavy vaginal bleeding. Which actions are appropriate? Select all that apply.
Correct answers: o1, o2, o3, o5
For a boggy uterus with heavy bleeding, the nurse massages the fundus until firm, measures the blood loss, ensures IV access and gives fluids and oxytocin as prescribed, and empties the bladder because a full bladder prevents the uterus from contracting. Sitting the client fully upright while withholding fluids and simply waiting both allow dangerous continued blood loss.
Why the other options are wrong
- o4. Placing the client fully upright (high Fowler's) decreases venous return to the heart and can cause severe orthostatic hypotension and syncope in a hypovolemic client. Withholding IV fluids is dangerous because fluid resuscitation is vital to maintain organ perfusion during hemorrhage. Key distinction: Keep the client flat or modified Trendelenburg and administer aggressive IV fluids.
- o6. Waiting an hour before taking action is unsafe because postpartum hemorrhage can lead to rapid hypovolemic shock and death within minutes. Immediate intervention is required to stop the bleeding. Key distinction: Take immediate action (massage the fundus) as soon as uterine atony or heavy bleeding is identified.
Key takeaway: Postpartum hemorrhage: massage the fundus, quantify loss, give fluids and oxytocin, and empty the bladder.
Which instructions are appropriate for a client with systemic lupus erythematosus? Select all that apply.
Correct answers: o1, o2, o4, o5
Clients with lupus protect their skin from the sun, report infection early (medicines and the disease lower immunity), balance activity with rest during flares, and report signs of kidney or organ involvement such as new swelling, blood in the urine, or increasing fatigue. Stopping medicines when a flare improves and spending time in the sun both trigger flares.
Why the other options are wrong
- o3. Prescribed controller medications (such as hydroxychloroquine or steroids) maintain immune suppression to prevent future flares; stopping them abruptly will trigger a rebound of autoimmune activity. Key distinction: Medication adherence is required long-term, and doses must be tapered under medical supervision, never stopped abruptly.
- o6. Sunlight exposure causes cell damage that releases cellular antigens, leading to increased autoantibody production and severe systemic flares. Key distinction: Sun exposure worsens both joint inflammation and cutaneous symptoms, so it must be avoided.
Key takeaway: Lupus care: sun protection, report infection and organ-involvement signs, pace activity; do not stop medicines or seek sun.
Shoulder dystocia is identified during a birth. Which actions are appropriate for the nurse and the birth team? Select all that apply.
Correct answers: o1, o2, o3, o4
Managing shoulder dystocia includes the McRoberts maneuver (hyperflexing the thighs), suprapubic pressure to free the anterior shoulder, calling for extra staff and the provider, and noting the time of head delivery so the duration is tracked. Fundal pressure is contraindicated because it worsens the impaction, and sitting the client upright to push harder does not relieve it.
Why the other options are wrong
- o5. Applying pressure to the fundus pushes the fetus downward, forcing the impacted shoulder tighter against the maternal pubic bone. Key distinction: This increases the risk of severe birth injuries, such as clavicle fracture or brachial plexus damage, and can cause maternal uterine rupture.
- o6. Sitting upright in high-Fowler's and pushing harder does not alter the pelvic angle or release the impacted shoulder. Key distinction: Pushing against a bone-on-bone obstruction will not deliver the body and only increases fetal distress and maternal tissue trauma.
Key takeaway: Shoulder dystocia: McRoberts, suprapubic pressure, call for help, and track the time; never use fundal pressure.