NCLEX Physiological Adaptation Flashcards

Question 1

Guillain-Barre biggest danger?

Accepted Answer

Respiratory failure (ascending paralysis reaches the diaphragm).

Question 2

What is the earliest sign of increased intracranial pressure?

Accepted Answer

A decreasing (altered) level of consciousness.

Question 3

DKA vs HHS key difference?

Accepted Answer

DKA has ketones + acidosis; HHS has very high glucose, no significant ketones.

Question 4

Tea-colored urine + edema + HTN after strep?

Accepted Answer

Acute glomerulonephritis.

Question 5

Arterial insufficiency ulcer position?

Accepted Answer

Dangle legs down (gravity helps arterial flow).

Question 6

Cushing's triad?

Accepted Answer

Bradycardia + widening pulse pressure + irregular respirations = late sign of ↑ICP.

Question 7

Cystic fibrosis confirmatory test?

Accepted Answer

Sweat chloride test (high chloride).

Question 8

tPA window for ischemic stroke?

Accepted Answer

Within 3–4.5 hours of last known well, after CT rules out hemorrhage.

Question 9

Tet spell relief position?

Accepted Answer

Knee-chest (or squatting) position.

Question 10

Most common congenital heart defect?

Accepted Answer

Ventricular septal defect (VSD).

Question 11

Which fetal heart rate deceleration is non-reassuring and reflects uteroplacental insufficiency?

Accepted Answer

Late decelerations.

Question 12

Sudden rigid, board-like abdomen = ?

Accepted Answer

Perforation/peritonitis — emergency.

Question 13

Multiple sclerosis trigger to avoid?

Accepted Answer

Overheating and stress.

Question 14

SIADH effect on sodium?

Accepted Answer

Hyponatremia (water retention); restrict fluids.

Question 15

Aortic dissection hallmark pain?

Accepted Answer

Sudden, severe, tearing chest/back pain.

Question 16

Left-brain stroke deficits?

Accepted Answer

Right-sided weakness + aphasia.

Question 17

Left-sided heart failure backs up where?

Accepted Answer

The lungs — crackles, dyspnea, orthopnea, pink frothy sputum.

Question 18

Normal ABG values?

Accepted Answer

pH 7.35–7.45 · CO₂ 35–45 · HCO₃ 22–26 · PaO₂ 80–100. Use ROME to classify.

Question 19

What is the normal fetal heart rate range?

Accepted Answer

110 to 160 beats per minute.

Question 20

ARDS hallmark?

Accepted Answer

Refractory hypoxemia (doesn't improve with O₂) + bilateral infiltrates.

Question 21

tPA window for ischemic stroke?

Accepted Answer

Within 3–4.5 h of last known well, after CT rules out bleed.

Question 22

Crohn's vs ulcerative colitis stool?

Accepted Answer

UC = bloody diarrhea; Crohn's = non-bloody with skip lesions.

Question 23

Kawasaki disease key risk?

Accepted Answer

Coronary artery aneurysm; high fever, strawberry tongue, red palms.

Question 24

Myxedema coma signs?

Accepted Answer

Hypothermia, bradycardia, decreased LOC.

Question 25

Silent chest in an asthma attack means?

Accepted Answer

Impending respiratory failure — emergency.

Question 26

What position eases breathing in acute pulmonary edema?

Accepted Answer

High Fowler (upright) with legs dependent.

Question 27

Atrial fibrillation main risk?

Accepted Answer

Clot formation → stroke; needs anticoagulation.

Question 28

Parkinson's classic triad?

Accepted Answer

Tremor (pill-rolling), rigidity, bradykinesia.

Question 29

Cystic fibrosis enzyme teaching?

Accepted Answer

Pancreatic enzymes with every meal and snack.

Question 30

Pediatric dehydration signs?

Accepted Answer

Sunken fontanel, no tears, decreased wet diapers, lethargy.

Question 31

What is the normal range for arterial blood pH?

Accepted Answer

7.35 to 7.45.

Question 32

Normal fasting glucose?

Accepted Answer

70–110 mg/dL. < 70 → give 15 g fast carbs, recheck in 15 min.

Question 33

ECG change in hyperkalemia?

Accepted Answer

Tall, peaked T waves (then widened QRS as it worsens). Hyperkalemia is a medical emergency — anticipate calcium gluconate to protect the heart, plus insulin/D50 to shift K⁺ into cells.

Question 34

What is the most dangerous electrolyte imbalance in oliguric acute kidney injury?

Accepted Answer

Hyperkalemia (risk of fatal arrhythmias).

Question 35

What 4 defects make up tetralogy of Fallot?

Accepted Answer

Pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy.

Question 36

Addison's disease = too little?

Accepted Answer

Cortisol/aldosterone (hypotension, hyperkalemia, bronze skin).

Question 37

What APGAR score range is considered normal?

Accepted Answer

7 to 10.

Question 38

Murphy's sign indicates?

Accepted Answer

Cholecystitis (RUQ pain on inspiration).

Question 39

What is the normal serum potassium range?

Accepted Answer

3.5 to 5.0 mEq/L.

Question 40

Acute pancreatitis nursing priority?

Accepted Answer

NPO to rest the pancreas, IV fluids, pain control.

Question 41

Thyroid storm signs?

Accepted Answer

High fever, severe tachycardia, agitation.

Question 42

Normal magnesium range?

Accepted Answer

1.5–2.5 mEq/L. Low → torsades/tremors; high → ↓reflexes, respiratory depression.

Question 43

Hyperventilation leads to which acid-base imbalance?

Accepted Answer

Respiratory alkalosis.

Question 44

What is the normal serum sodium range?

Accepted Answer

135 to 145 mEq/L.

Question 45

Addisonian crisis vs Cushing's?

Accepted Answer

Addison = adrenal INSUFFICIENCY (hypotension, hyperkalemia, bronze skin). Cushing's = EXCESS cortisol.

Question 46

Right-sided heart failure backs up where?

Accepted Answer

The body — peripheral edema, JVD, hepatomegaly, weight gain.

Question 47

Pyloric stenosis hallmark?

Accepted Answer

Projectile vomiting, hunger after vomiting, olive-shaped mass.

Question 48

Thyroid storm vs myxedema?

Accepted Answer

Storm (hyper): fever, tachycardia, agitation. Myxedema coma (hypo): hypothermia, bradycardia, ↓LOC.

Question 49

What is the earliest sign of magnesium sulfate toxicity?

Accepted Answer

Loss of deep tendon reflexes.

Question 50

Classic MI pain pattern?

Accepted Answer

Crushing substernal pain radiating to left arm/jaw, diaphoresis.

Question 51

Cirrhosis + confusion + high ammonia treatment?

Accepted Answer

Lactulose (titrate to 2–3 soft stools/day).

Question 52

Most common pediatric leukemia?

Accepted Answer

Acute lymphocytic leukemia (ALL).

Question 53

Diabetes insipidus effect on output?

Accepted Answer

Huge dilute urine, hypernatremia; give desmopressin.

Question 54

Venous insufficiency leg care?

Accepted Answer

Elevate legs and apply compression.

Question 55

Costovertebral (flank) tenderness + fever?

Accepted Answer

Pyelonephritis.

Question 56

COPD target oxygen saturation?

Accepted Answer

88–92% with controlled low-flow O₂.

Question 57

First treatment in DKA?

Accepted Answer

IV fluids, then insulin; replace potassium as it shifts into cells.

Question 58

Cushing's syndrome = too much?

Accepted Answer

Cortisol (moon face, hyperglycemia, hypertension).

Question 59

Anemia common signs?

Accepted Answer

Fatigue, pallor, tachycardia, dyspnea on exertion.

Question 60

Normal potassium range?

Accepted Answer

3.5–5.0 mEq/L. High → peaked T waves & lethal dysrhythmias; low → flat T/U waves, ↑digoxin toxicity.

Question 61

Beck's triad (cardiac tamponade)?

Accepted Answer

Muffled heart sounds, JVD, hypotension.

Question 62

Normal calcium range?

Accepted Answer

9.0–10.5 mg/dL. Low → tetany, +Chvostek/Trousseau; high → weakness, stones, ↓reflexes.

Question 63

Jaundice appearing in the first 24 hours of life is classified as what?

Accepted Answer

Pathologic jaundice.

Question 64

Right-brain stroke deficits?

Accepted Answer

Left-sided weakness + neglect/impulsivity.

NCLEX Physiological Adaptation Flashcards

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