D454 Adult Health III WGU Objective
Assessment Nursing OA 2026/2027 –
100% Verified Questions and Answers
with Rationale (GRADED A+)
Question 1
A client with heart failure reports increasing shortness of breath and
difficulty sleeping flat. Which finding requires the nurse's immediate
attention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg over 3 days
C. Oxygen saturation of 86%
D. Fatigue when performing activities
Answer: _C. Oxygen saturation of 86%_
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires immediate assessment and intervention. The other findings
are also consistent with worsening heart failure but are not as
immediately threatening to oxygenation.
Question 2
,A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing action is appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen therapy at the prescribed target level
C. Discontinue oxygen if the client's respiratory rate decreases
D. Encourage the client to breathe rapidly and deeply
Answer: _B. Maintain oxygen therapy at the prescribed target level_
Rationale: Oxygen should be administered carefully in clients with
COPD according to the prescribed target saturation and clinical
condition. Excessive oxygen can contribute to worsening hypercapnia in
susceptible clients.
Question 3
A client with diabetic ketoacidosis (DKA) is admitted to the emergency
department. Which intervention should the nurse anticipate first?
A. Administration of IV isotonic fluids
B. Administration of long-acting insulin
C. Restriction of oral fluids
D. Administration of potassium before laboratory testing
Answer: _A. Administration of IV isotonic fluids_
Rationale: Severe dehydration is a major consequence of DKA. Initial
management generally includes rapid IV fluid replacement, followed by
insulin therapy and careful electrolyte management.
Question 4
,A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is the priority for the nurse to assess?
A. Muscle cramps
B. Cardiac rhythm
C. Urine color
D. Skin turgor
Answer: _B. Cardiac rhythm_
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring and prompt intervention
are priorities.
Question 5
A client with cirrhosis develops confusion and altered level of
consciousness. Which medication does the nurse anticipate
administering to reduce ammonia levels?
A. Furosemide
B. Lactulose
C. Omeprazole
D. Metoprolol
Answer: _B. Lactulose_
Rationale: Lactulose decreases the absorption of ammonia from the
gastrointestinal tract and is commonly used to treat hepatic
encephalopathy associated with cirrhosis.
Question 6
, A client with a suspected pulmonary embolism suddenly develops
dyspnea, chest pain, and tachycardia. What is the nurse's priority action?
A. Encourage ambulation
B. Apply oxygen and assess respiratory status
C. Place the client in a supine position
D. Administer oral fluids
Answer: _B. Apply oxygen and assess respiratory status_
Rationale: A suspected pulmonary embolism can rapidly compromise
oxygenation. Supporting airway and breathing and promptly assessing
respiratory status are immediate priorities.
Question 7
A client is admitted with acute ischemic stroke. Which assessment is
most important before administering anything orally?
A. Pupillary response
B. Swallowing ability
C. Handgrip strength
D. Deep tendon reflexes
Answer: _B. Swallowing ability_
Rationale: Stroke can impair the swallowing reflex and place the client
at high risk for aspiration. A swallowing assessment should occur before
oral food, fluids, or medications are given.
Question 8
A client receiving a heparin infusion has a markedly elevated aPTT.
Which action should the nurse anticipate?
Assessment Nursing OA 2026/2027 –
100% Verified Questions and Answers
with Rationale (GRADED A+)
Question 1
A client with heart failure reports increasing shortness of breath and
difficulty sleeping flat. Which finding requires the nurse's immediate
attention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg over 3 days
C. Oxygen saturation of 86%
D. Fatigue when performing activities
Answer: _C. Oxygen saturation of 86%_
Rationale: An oxygen saturation of 86% indicates significant hypoxemia
and requires immediate assessment and intervention. The other findings
are also consistent with worsening heart failure but are not as
immediately threatening to oxygenation.
Question 2
,A client with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy. Which nursing action is appropriate?
A. Administer oxygen at the highest possible flow rate
B. Maintain oxygen therapy at the prescribed target level
C. Discontinue oxygen if the client's respiratory rate decreases
D. Encourage the client to breathe rapidly and deeply
Answer: _B. Maintain oxygen therapy at the prescribed target level_
Rationale: Oxygen should be administered carefully in clients with
COPD according to the prescribed target saturation and clinical
condition. Excessive oxygen can contribute to worsening hypercapnia in
susceptible clients.
Question 3
A client with diabetic ketoacidosis (DKA) is admitted to the emergency
department. Which intervention should the nurse anticipate first?
A. Administration of IV isotonic fluids
B. Administration of long-acting insulin
C. Restriction of oral fluids
D. Administration of potassium before laboratory testing
Answer: _A. Administration of IV isotonic fluids_
Rationale: Severe dehydration is a major consequence of DKA. Initial
management generally includes rapid IV fluid replacement, followed by
insulin therapy and careful electrolyte management.
Question 4
,A client with chronic kidney disease has a potassium level of 6.4 mEq/L.
Which finding is the priority for the nurse to assess?
A. Muscle cramps
B. Cardiac rhythm
C. Urine color
D. Skin turgor
Answer: _B. Cardiac rhythm_
Rationale: Severe hyperkalemia can cause life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring and prompt intervention
are priorities.
Question 5
A client with cirrhosis develops confusion and altered level of
consciousness. Which medication does the nurse anticipate
administering to reduce ammonia levels?
A. Furosemide
B. Lactulose
C. Omeprazole
D. Metoprolol
Answer: _B. Lactulose_
Rationale: Lactulose decreases the absorption of ammonia from the
gastrointestinal tract and is commonly used to treat hepatic
encephalopathy associated with cirrhosis.
Question 6
, A client with a suspected pulmonary embolism suddenly develops
dyspnea, chest pain, and tachycardia. What is the nurse's priority action?
A. Encourage ambulation
B. Apply oxygen and assess respiratory status
C. Place the client in a supine position
D. Administer oral fluids
Answer: _B. Apply oxygen and assess respiratory status_
Rationale: A suspected pulmonary embolism can rapidly compromise
oxygenation. Supporting airway and breathing and promptly assessing
respiratory status are immediate priorities.
Question 7
A client is admitted with acute ischemic stroke. Which assessment is
most important before administering anything orally?
A. Pupillary response
B. Swallowing ability
C. Handgrip strength
D. Deep tendon reflexes
Answer: _B. Swallowing ability_
Rationale: Stroke can impair the swallowing reflex and place the client
at high risk for aspiration. A swallowing assessment should occur before
oral food, fluids, or medications are given.
Question 8
A client receiving a heparin infusion has a markedly elevated aPTT.
Which action should the nurse anticipate?
