12,241 verified 4-option questions Double-checked by independent solution

NCLEX-RN Unexpected response to therapies practice questions

4 questions · answers open · no sign-up

These are original practice items written to the NCLEX-RN blueprint (4 options, no penalty for wrong answers), not actual exam questions. Try each one before you open the answer.

What this topic covers

Unexpected response to therapies sits inside the Physiological Adaptation category of the NCLEX-RN. Our bank holds 38 verified items tagged to it, and the 4 below are a fixed sample so the page stays the same every time you open it. Each one shows the reasoning, not just the letter.

The topic tag comes from our own items rather than from a published syllabus, so treat it as a map of what we cover. For the official category breakdown see the NCLEX-RN page.

Unexpected response to therapies sample questions

Question 1

A 52-year-old client with acute myeloid leukemia is receiving their first dose of intravenous cytarabine. Fifteen minutes into the infusion, the client reports sudden chest tightness, dyspnea, and a feeling of throat swelling. Vital signs: heart rate 124 bpm, blood pressure 86/50 mm Hg, respiratory rate 28/min, oxygen saturation 89% on room air. The nurse notes urticaria on the client's trunk. What is the nurse's priority action?

  1. A Apply a non-rebreather mask at 15 L/min and prepare for intubation.
  2. B Stop the cytarabine infusion immediately and maintain the IV access.
  3. C Administer epinephrine 0.3 mg intramuscularly in the anterolateral thigh.
  4. D Slow the cytarabine infusion rate and administer diphenhydramine 50 mg IV.
Show the answer and explanation

Correct answer: B

Throat swelling, dyspnea, hypotension, hypoxemia and urticaria indicate anaphylaxis. The first step is to stop the infusion to end exposure to the drug while keeping IV access, then give epinephrine and call for help.

Why the other options are wrong:
A: Oxygen and airway support are needed, but the drug must be stopped first.
C: Epinephrine is the first-line drug and is given immediately after the infusion is stopped.
D: Slowing the infusion continues exposure, and an antihistamine alone cannot treat anaphylaxis.

Question 2

A 55-year-old client with a history of heart failure is receiving intravenous furosemide 40 mg twice daily. After 48 hours of therapy, the nurse reviews the laboratory results: serum sodium 138 mEq/L, potassium 3.1 mEq/L, chloride 98 mEq/L, and creatinine 1.2 mg/dL. Which finding requires the nurse's immediate action?

  1. A Serum chloride 98 mEq/L
  2. B Serum creatinine 1.2 mg/dL
  3. C Serum potassium 3.1 mEq/L
  4. D Serum sodium 138 mEq/L
Show the answer and explanation

Correct answer: C

Furosemide causes potassium loss, and a potassium of 3.1 mEq/L is below the normal range of 3.5 to 5.0 mEq/L. Hypokalemia can cause dysrhythmias and muscle weakness in a client with heart failure, so the nurse must report it and anticipate replacement.

Why the other options are wrong:
A: A chloride of 98 mEq/L is within normal limits.
B: A creatinine of 1.2 mg/dL is at the upper limit of normal and is not an acute change requiring immediate action.
D: A sodium of 138 mEq/L is within the normal range.

Question 3

A 60-year-old client is receiving a transfusion of packed red blood cells for anemia. Fifteen minutes after the transfusion begins, the client reports chills, lower back pain, and feels 'flushed.' Vital signs: BP 90/58 mm Hg, HR 112/min, RR 24/min, temperature 38.9°C. Which action should the nurse take first?

  1. A Slow the transfusion rate and monitor vital signs every 5 minutes
  2. B Notify the healthcare provider and wait for further orders before acting
  3. C Administer diphenhydramine 25 mg IV as prescribed for allergic reaction
  4. D Stop the transfusion immediately and maintain IV access with 0.9% sodium chloride
Show the answer and explanation

Correct answer: D

Chills, back pain, flushing, fever, hypotension and tachycardia soon after a transfusion begins suggest an acute hemolytic reaction. Stopping the transfusion immediately limits exposure, and keeping the line open with 0.9% sodium chloride through new tubing preserves access for treatment.

Why the other options are wrong:
A: Slowing the rate still infuses the incompatible blood and allows the reaction to worsen.
B: Waiting for orders delays stopping the transfusion, which the nurse must do first.
C: Diphenhydramine treats mild allergic reactions and does not address hemolysis or hypotension.

Question 4

A 45-year-old client with end-stage renal disease is undergoing hemodialysis. Thirty minutes into the treatment, the client reports severe headache, nausea, and blurred vision. The nurse measures blood pressure at 210/110 mm Hg. Which action by the nurse is most important?

  1. A Decrease the ultrafiltration rate by 50% and reassess
  2. B Administer ondansetron 4 mg intravenously for nausea
  3. C Check the client's serum potassium level immediately
  4. D Slow the dialysis rate and notify the nephrologist
Show the answer and explanation

Correct answer: D

Headache, nausea, and blurred vision early in hemodialysis, with marked hypertension, suggest dialysis disequilibrium syndrome: urea leaves the blood faster than the brain, drawing water into brain tissue. Slowing the dialysis rate and notifying the nephrologist helps prevent progression to seizures or coma.

Why the other options are wrong:
A: Ultrafiltration removes fluid, not solutes, so lowering it does not slow the rapid solute shift that causes disequilibrium.
B: An antiemetic treats one symptom and does nothing for the brain swelling causing it.
C: Potassium does not explain these neurologic symptoms, and checking it delays the needed intervention.

The whole NCLEX-RN bank

2,666 verified questions with explanations, timed category tests and an 85-item full-length practice test, a review pool that brings back what you missed until you get it right, and an AI tutor that explains why. One payment per exam, or one bundle for all of them.

NCLEX-RN practice opens soon: 2,666 questions verified so far. Purchase opens automatically when the bank is complete. About the NCLEX-RN

Related pages

All NCLEX-RN sample questions 8 categorys All Physiological Adaptation questions 3 topics Hemodynamics with explanations Alterations in body systems with explanations TEAS 7 sample questions with explanations HESI A2 sample questions with explanations

TEAS is a registered trademark of Assessment Technologies Institute, LLC; HESI is a registered trademark of Elsevier Inc. NCLEX and NCLEX-RN are registered trademarks of the National Council of State Boards of Nursing, Inc. (NCSBN). AdmitNurse is an independent practice service, not affiliated with or endorsed by any of these organizations.