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Physiological Adaptation

NCLEX Endocrine Practice Questions

Quick answer

Endocrine questions on the NCLEX-RN sit inside Physiological Adaptation and cover the emergencies: DKA, thyroid storm, myxedema coma, adrenal crisis, and the water problems of SIADH and diabetes insipidus. Expect three to five items per exam, most of them asking what you do first or which lab you report.

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Endocrine is where the exam checks whether you can read a lab panel and a set of vital signs together and recognize a pattern. Nearly every disorder in this group has an "opposite twin": hyperthyroid and hypothyroid, Cushing's and Addison's, SIADH and diabetes insipidus. The test writers love to put the twin's findings in the wrong options. The trap that catches students most often is treating the glucose number as the emergency in DKA and reaching for insulin before fluids, or forgetting that insulin pushes potassium into the cells and can leave a client with a dangerous low level an hour later. Slow down on the stem, find the one value that is actually threatening the airway, the heart or the brain, and act on that.

Practice questions

1

A client with type 1 diabetes arrives with a glucose of 540 mg/dL, pH 7.21, serum potassium 3.2 mEq/L, deep rapid respirations and a fruity breath odor. The provider orders a 1 liter bolus of 0.9% sodium chloride, a regular insulin infusion, potassium chloride 20 mEq in the next liter, and hourly glucose checks. Which order should the nurse carry out first?

  1. AStart the regular insulin infusion
  2. BHang the 1 liter bolus of 0.9% sodium chloride
  3. CAdd potassium chloride to the running fluids
  4. DBegin hourly fingerstick glucose checks
Show answer

Answer: B

The client is severely dehydrated from osmotic diuresis, and the first threat is poor perfusion, so isotonic fluid goes in first. Fluid alone starts lowering the glucose and improves the acidosis before any insulin is given.

Why the others are wrong

Option A is unsafe right now because the potassium is already 3.2 mEq/L and insulin will drive it lower; the infusion waits until potassium is at least 3.3 mEq/L. Option C comes next, after the bolus and before the insulin, but it is not the first step. Option D is monitoring, and monitoring never comes before a treatment that fixes perfusion.

2

A client in DKA has been on a regular insulin infusion for three hours. The glucose has dropped from 520 mg/dL to 240 mg/dL and the most recent potassium is 3.1 mEq/L. Which action should the nurse take?

  1. AStop the insulin infusion because the glucose is now under 250 mg/dL
  2. BNotify the provider, anticipate adding dextrose to the fluids and replacing potassium while the insulin continues
  3. CIncrease the insulin rate to clear the remaining ketones faster
  4. DGive the client a snack with 30 grams of carbohydrate
Show answer

Answer: B

When the glucose reaches about 200 to 250 mg/dL, dextrose is added to the IV fluid so the insulin can keep running to clear the ketones without causing hypoglycemia. Potassium at 3.1 mEq/L needs replacement now, because every hour of insulin pushes more of it into the cells and the heart is at risk.

Why the others are wrong

Option A stops ketone clearance too early, since the acidosis, not the glucose, is what the insulin is treating. Option C speeds the potassium drop and raises the risk of cerebral edema from a fast osmolar shift. Option D is not reliable in a client who may be nauseated and does not address the potassium at all.

3

A client with Graves' disease is admitted with pneumonia. Temperature is 104.2 F, heart rate 148, the client is confused and the skin is hot and flushed. The provider writes orders for propranolol, propylthiouracil, hydrocortisone, and aspirin 650 mg for the fever. Which order should the nurse question?

  1. APropranolol
  2. BPropylthiouracil
  3. CHydrocortisone
  4. DAspirin
Show answer

Answer: D

This is thyroid storm, triggered by the infection. Aspirin displaces thyroid hormone from its binding proteins and raises the free hormone level, which makes the storm worse. Acetaminophen and cooling blankets are used for the fever instead.

Why the others are wrong

Propranolol slows the heart and blocks the adrenergic symptoms, propylthiouracil stops new hormone production, and hydrocortisone covers the adrenal insufficiency that comes with the stress of storm and slows conversion of T4 to T3. All three are expected treatments.

4

An 81 year old client with a history of hypothyroidism who stopped taking levothyroxine months ago is brought in by family. Temperature is 93.4 F, heart rate 46, respirations 7 and shallow, and the client responds only to painful stimuli. Which action should the nurse take first?

  1. AApply a warming blanket set to high
  2. BAssess the airway and prepare for ventilation support
  3. CGive the ordered IV levothyroxine
  4. DDraw the thyroid panel and cortisol level
Show answer

Answer: B

This is myxedema coma, and a respiratory rate of 7 with depressed consciousness means the client is at risk of carbon dioxide retention and respiratory arrest. Airway and breathing come before any medication or lab work.

Why the others are wrong

Option A is dangerous because rapid external rewarming causes vasodilation and can drop the blood pressure into shock; passive warming with regular blankets is used. Option C is the correct treatment but is given after the airway is secured. Option D supports the diagnosis but a lab draw does not change the immediate priority.

5

A client with Addison's disease is being discharged after an admission for adrenal crisis that started with a stomach virus. Which statement by the client shows the teaching was understood?

  1. A"I will stop the hydrocortisone once my energy comes back so I don't get hooked on it."
  2. B"If I get a fever or start vomiting, I will take extra hydrocortisone and call the office, and I will use my injection kit if I can't keep pills down."
  3. C"I should cut salt out of my diet to keep my blood pressure under control."
  4. D"I only need to take the medication on days when I feel stressed."
Show answer

Answer: B

Illness, fever and vomiting raise the body's need for cortisol. A client with Addison's disease cannot make more on their own, so the dose is increased during illness and switched to an injectable form when oral intake fails. That is exactly how this admission could have been prevented.

Why the others are wrong

Option A describes stopping the drug abruptly, which is the most common cause of adrenal crisis. Option C is backwards, since Addison's causes sodium loss and clients are told to keep a normal to liberal salt intake. Option D misses that replacement is lifelong and daily, not situational.

6

The nurse is assessing a client with a six month history of unexplained changes and suspects Cushing's syndrome. Which group of findings supports that suspicion?

  1. AWeight loss, bronze skin color, low blood pressure, salt craving
  2. BRound face, fat pad between the shoulders, thin skin with purple stretch marks, glucose 212 mg/dL
  3. CBulging eyes, fine tremor, weight loss, heat intolerance
  4. DPuffy face, dry coarse skin, constipation, heart rate 52
Show answer

Answer: B

Excess cortisol redistributes fat to the face, trunk and upper back, thins the skin and breaks down collagen (the striae), and raises blood glucose. Hypertension, hypokalemia and easy bruising are also typical.

Why the others are wrong

Option A is Addison's disease, the cortisol deficiency picture. Option C is hyperthyroidism. Option D is hypothyroidism. These are the exact "twin" distractors the exam uses, so learn each group as a set.

7

Twelve hours after surgery to remove a pituitary tumor, a client's urine output has been 450 to 600 mL every hour for three hours. Urine specific gravity is 1.002 and the client reports intense thirst. Which action should the nurse take?

  1. ARestrict oral fluids to 1,000 mL for the rest of the shift
  2. BNotify the provider and anticipate an order for desmopressin
  3. CInsert a urinary catheter and continue to monitor
  4. DEncourage the client to drink only when thirsty
Show answer

Answer: B

Pituitary surgery can cut off antidiuretic hormone, causing diabetes insipidus. Large volumes of very dilute urine with thirst is the picture, and the client will lose water faster than they can drink it. Desmopressin replaces the missing hormone, and the nurse also matches intake to output and watches the sodium, which climbs as water is lost.

Why the others are wrong

Option A worsens the dehydration and drives the sodium higher. Option C may be ordered for accurate measurement but does nothing to stop the loss. Option D relies on thirst alone, which fails once the client is drowsy or asleep.

8

A client with small cell lung cancer is admitted with a serum sodium of 119 mEq/L, headache, nausea and increasing confusion. The urine is concentrated and the client is not edematous. Which provider order should the nurse question?

  1. ASeizure precautions
  2. BFluid restriction of 800 mL per day
  3. CDextrose 5% in water at 100 mL per hour
  4. DSerum sodium every 4 hours
Show answer

Answer: C

This is SIADH, where the body holds on to water and dilutes the sodium. Dextrose 5% in water becomes free water once the sugar is metabolized, so it would push the sodium even lower and could cause seizures or brain swelling. Hypotonic fluids are contraindicated; severe cases get small amounts of 3% hypertonic saline under close monitoring.

Why the others are wrong

Seizure precautions are needed because a sodium under 120 mEq/L can trigger seizures at any moment. Fluid restriction is the main treatment for SIADH. Frequent sodium checks are needed because correcting too quickly causes nerve damage in the brainstem.

9

A client admitted with a suspected pheochromocytoma has a blood pressure of 218/124, a pounding headache, sweating and a heart rate of 128. Which nursing action is contraindicated?

  1. AKeeping the room quiet and dim
  2. BPalpating the abdomen during the physical assessment
  3. CRaising the head of the bed
  4. DMonitoring the blood pressure every 15 minutes
Show answer

Answer: B

A pheochromocytoma is a tumor on the adrenal gland that releases catecholamines. Pressing on the abdomen can squeeze the tumor and trigger a sudden release, sending the blood pressure to a level that causes stroke or heart failure. The nurse avoids abdominal palpation and anything else that stimulates the client.

Why the others are wrong

A calm environment lowers stimulation and is helpful. Raising the head of the bed helps with the headache and is safe. Frequent blood pressure monitoring is expected during a hypertensive crisis.

10

Six hours after a total thyroidectomy, the nurse rounds on a client. Which finding requires the most immediate action?

  1. AA slightly hoarse voice when the client speaks
  2. BTingling around the mouth and in the fingertips
  3. CA feeling of tightness in the neck, difficulty swallowing saliva and a muffled voice
  4. DA small amount of dried blood on the dressing edge
Show answer

Answer: C

Neck tightness, trouble swallowing and a change in voice quality point to a hematoma under the incision pressing on the trachea. This is an airway emergency. The nurse calls for help, loosens the dressing, and makes sure the tracheostomy tray kept at the bedside is ready, because the airway can close within minutes.

Why the others are wrong

Option A is common after the breathing tube and surgical handling of the area and usually resolves; it is monitored, not treated urgently. Option B is an early sign of hypocalcemia from disturbed parathyroid glands and must be reported and the calcium checked, but it is not an airway threat and comes second to option C. Option D is expected and only needs the dressing marked and rechecked.

Quick tips

  • Learn the three DKA steps in order and never swap them: isotonic fluid, then potassium if it is under 3.3 mEq/L, then the insulin infusion. Dextrose gets added to the fluid near 200 to 250 mg/dL so the insulin can keep clearing ketones.
  • HHS looks like DKA with the volume turned up and the ketones turned off: glucose often over 600 mg/dL, no acidosis, extreme dehydration, and more neurological changes. Treatment is still fluids first.
  • Build the "twin" tables before test day. Hyperthyroid and Cushing's run hot, fast and high. Hypothyroid and Addison's run cold, slow and low. Diabetes insipidus is too much dilute urine with high sodium. SIADH is too little concentrated urine with low sodium.
  • Any endocrine crisis question with a respiratory rate under 10, a swollen neck or a sodium under 120 mEq/L is really an airway or seizure question. Pick the option that protects the airway or the brain.
  • For a client who cannot swallow safely and has a low glucose, nothing goes by mouth. Use IV dextrose when there is IV access and glucagon IM when there is not, then roll the client onto the side.

Related topics

FAQ

What is the difference between DKA and HHS on the NCLEX?

DKA is usually type 1, glucose around 300 to 600 mg/dL, with ketones, a pH under 7.30 and Kussmaul breathing. HHS is usually type 2 and older adults, glucose often above 600 mg/dL, no significant ketones or acidosis, and much worse dehydration and confusion. Both get fluids first.

How do I remember Addison's vs Cushing's for the exam?

Addison's is "adds on" nothing: low cortisol, low sodium, low glucose, low blood pressure, high potassium, bronze skin. Cushing's is the cushion: extra fat on the face and trunk, high glucose, high blood pressure, low potassium, thin skin that bruises. If you know one, flip every finding for the other.

What do I check after a thyroidectomy?

Airway first: neck swelling, voice change, trouble swallowing, stridor. Then calcium: tingling around the mouth or fingers, muscle twitching, a positive Chvostek or Trousseau sign. Keep a trach tray and IV calcium gluconate at the bedside and keep the head of the bed raised.

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