WGU D455 Exit HESI HCV2| 50 Comprehensive Questions and Answers with
Rationale | Latest Update 2026/2027 | Graded A+
Question 1
In caring for a client with Cushing syndrome, which serum laboratory value is most important for the
nurse to monitor?
• A. Serum potassium
• B. Serum calcium
• C. Serum magnesium
• D. Serum sodium ✓
Rationale: Cushing syndrome causes excessive cortisol production, which leads to sodium and water
retention (hypernatremia) and potassium loss (hypokalemia). While both sodium and potassium are
important to monitor, serum sodium is the priority because severe hypernatremia can cause
neurological symptoms including confusion, seizures, and coma. The classic presentation of Cushing
syndrome includes "moon face," "buffalo hump," central obesity, purple striae, and hypertension—all
related to sodium retention.
Question 2
The mother of an infant brings the infant to the clinic because the skin in the diaper area is excoriated
and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which
nursing intervention should the nurse implement?
• A. Apply a thick layer of petroleum jelly to the area
• B. Instruct the mother to change the diaper more often
• C. Use baby wipes with alcohol to clean the area
• D. Apply talcum powder to the affected area after each diaper change
Rationale: Petroleum jelly creates a protective barrier that prevents further irritation from urine and
feces while allowing the skin to heal. Frequent diaper changes (B) would also help, but the question asks
for the specific intervention to implement for the current excoriation—barrier protection is the most
immediate therapeutic action. Alcohol-based wipes (C) would further irritate the damaged skin, and
talcum powder (D) can cause respiratory issues if inhaled and may worsen irritation.
Question 3
A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the
nurse provide this client regarding diet?
, • A. Increase the amount of leafy green vegetables in the diet
• B. Eat approximately the same amount of leafy green vegetables daily so the amount of
vitamin K consumed is consistent ✓
• C. Take a vitamin K supplement daily
• D. Avoid eating any leafy green vegetables
Rationale: Warfarin works by antagonizing vitamin K. Consistency in vitamin K intake is essential because
sudden changes can alter the International Normalized Ratio (INR) and affect anticoagulation stability.
Patients should maintain their usual dietary habits rather than eliminating (D) or significantly increasing
(A) vitamin K-rich foods. Taking vitamin K supplements (C) would counteract the warfarin's effect.
Question 4
An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at
the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot
remember when he took his last dose of insulin or ate last. What action should the nurse implement
first?
• A. Check the client's capillary blood glucose ✓
• B. Start an intravenous (IV) infusion of normal saline
• C. Administer a dose of rapid-acting insulin
• D. Obtain a urine sample for ketone testing
Rationale: In a client with type 1 diabetes presenting with abdominal cramping, vomiting, lethargy, and
confusion, the priority is to assess blood glucose level immediately. These symptoms suggest possible
diabetic ketoacidosis (DKA) or severe hyperglycemia. Treatment decisions (IV fluids, insulin
administration) cannot be made without knowing the current glucose level. While the rationale
mentioned IV fluids, assessing glucose is the correct first action per nursing prioritization (ABCs—glucose
is a metabolic assessment priority).
Question 5
A client requests a stronger pain medication than prescribed acetaminophen. What should the nurse
do?
• A. Administer a placebo to assess the client's true pain level
• B. Document the client's complaint and reassess in one hour
• C. Administer the prescribed dose of acetaminophen as ordered
• D. Contact the healthcare provider to request a stronger analgesic ✓
, Rationale: The nurse should first reassess the client's pain using a valid pain scale, then contact the
healthcare provider if the current medication is inadequate. The nurse cannot independently change the
medication order. Administering acetaminophen as ordered (C) without addressing the client's report of
inadequate relief would be inappropriate. Administering a placebo (A) is unethical and violates the
client's rights.
Question 6
When teaching a class about blood glucose monitoring for clients with diabetes during acute illness,
when should the nurse emphasize checking glucose levels?
• A. When experiencing symptoms of hyperglycemia or hypoglycemia ✓
• B. Only before meals to adjust insulin dosage
• C. During periods of decreased physical activity
• D. Once a week to monitor long-term glucose control
Rationale: During acute illness, blood glucose levels can fluctuate rapidly. Sick day rules for diabetes
management emphasize that clients should check glucose more frequently—typically every 2-4 hours—
especially when experiencing symptoms. Relying only on symptoms (A) is actually insufficient; they
should check regularly even without symptoms. However, among the options given, A is the best answer.
During illness, clients should also check for ketones and never skip insulin doses.
Question 7
A client being admitted reports a recent MRSA wound infection. What action should the nurse take?
• A. Initiate standard precautions and continue to monitor for signs of infection
• B. Obtain a wound culture and wait for the results before taking action
• C. Place the client on contact transmission precautions ✓
• D. Administer vancomycin immediately
Rationale: MRSA (Methicillin-Resistant Staphylococcus aureus) requires Contact Precautions to prevent
transmission to other patients and healthcare workers. This includes wearing gloves and gown for all
interactions, using dedicated equipment, and placing the client in a private room if possible. Standard
precautions alone (A) are insufficient for known MRSA. Obtaining a culture (B) may be appropriate but
should not delay implementing precautions. Vancomycin (D) requires a provider order and culture
sensitivity results.
Question 8
Rationale | Latest Update 2026/2027 | Graded A+
Question 1
In caring for a client with Cushing syndrome, which serum laboratory value is most important for the
nurse to monitor?
• A. Serum potassium
• B. Serum calcium
• C. Serum magnesium
• D. Serum sodium ✓
Rationale: Cushing syndrome causes excessive cortisol production, which leads to sodium and water
retention (hypernatremia) and potassium loss (hypokalemia). While both sodium and potassium are
important to monitor, serum sodium is the priority because severe hypernatremia can cause
neurological symptoms including confusion, seizures, and coma. The classic presentation of Cushing
syndrome includes "moon face," "buffalo hump," central obesity, purple striae, and hypertension—all
related to sodium retention.
Question 2
The mother of an infant brings the infant to the clinic because the skin in the diaper area is excoriated
and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which
nursing intervention should the nurse implement?
• A. Apply a thick layer of petroleum jelly to the area
• B. Instruct the mother to change the diaper more often
• C. Use baby wipes with alcohol to clean the area
• D. Apply talcum powder to the affected area after each diaper change
Rationale: Petroleum jelly creates a protective barrier that prevents further irritation from urine and
feces while allowing the skin to heal. Frequent diaper changes (B) would also help, but the question asks
for the specific intervention to implement for the current excoriation—barrier protection is the most
immediate therapeutic action. Alcohol-based wipes (C) would further irritate the damaged skin, and
talcum powder (D) can cause respiratory issues if inhaled and may worsen irritation.
Question 3
A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the
nurse provide this client regarding diet?
, • A. Increase the amount of leafy green vegetables in the diet
• B. Eat approximately the same amount of leafy green vegetables daily so the amount of
vitamin K consumed is consistent ✓
• C. Take a vitamin K supplement daily
• D. Avoid eating any leafy green vegetables
Rationale: Warfarin works by antagonizing vitamin K. Consistency in vitamin K intake is essential because
sudden changes can alter the International Normalized Ratio (INR) and affect anticoagulation stability.
Patients should maintain their usual dietary habits rather than eliminating (D) or significantly increasing
(A) vitamin K-rich foods. Taking vitamin K supplements (C) would counteract the warfarin's effect.
Question 4
An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at
the clinic with abdominal cramping and vomiting. He is lethargic, moderately confused, and cannot
remember when he took his last dose of insulin or ate last. What action should the nurse implement
first?
• A. Check the client's capillary blood glucose ✓
• B. Start an intravenous (IV) infusion of normal saline
• C. Administer a dose of rapid-acting insulin
• D. Obtain a urine sample for ketone testing
Rationale: In a client with type 1 diabetes presenting with abdominal cramping, vomiting, lethargy, and
confusion, the priority is to assess blood glucose level immediately. These symptoms suggest possible
diabetic ketoacidosis (DKA) or severe hyperglycemia. Treatment decisions (IV fluids, insulin
administration) cannot be made without knowing the current glucose level. While the rationale
mentioned IV fluids, assessing glucose is the correct first action per nursing prioritization (ABCs—glucose
is a metabolic assessment priority).
Question 5
A client requests a stronger pain medication than prescribed acetaminophen. What should the nurse
do?
• A. Administer a placebo to assess the client's true pain level
• B. Document the client's complaint and reassess in one hour
• C. Administer the prescribed dose of acetaminophen as ordered
• D. Contact the healthcare provider to request a stronger analgesic ✓
, Rationale: The nurse should first reassess the client's pain using a valid pain scale, then contact the
healthcare provider if the current medication is inadequate. The nurse cannot independently change the
medication order. Administering acetaminophen as ordered (C) without addressing the client's report of
inadequate relief would be inappropriate. Administering a placebo (A) is unethical and violates the
client's rights.
Question 6
When teaching a class about blood glucose monitoring for clients with diabetes during acute illness,
when should the nurse emphasize checking glucose levels?
• A. When experiencing symptoms of hyperglycemia or hypoglycemia ✓
• B. Only before meals to adjust insulin dosage
• C. During periods of decreased physical activity
• D. Once a week to monitor long-term glucose control
Rationale: During acute illness, blood glucose levels can fluctuate rapidly. Sick day rules for diabetes
management emphasize that clients should check glucose more frequently—typically every 2-4 hours—
especially when experiencing symptoms. Relying only on symptoms (A) is actually insufficient; they
should check regularly even without symptoms. However, among the options given, A is the best answer.
During illness, clients should also check for ketones and never skip insulin doses.
Question 7
A client being admitted reports a recent MRSA wound infection. What action should the nurse take?
• A. Initiate standard precautions and continue to monitor for signs of infection
• B. Obtain a wound culture and wait for the results before taking action
• C. Place the client on contact transmission precautions ✓
• D. Administer vancomycin immediately
Rationale: MRSA (Methicillin-Resistant Staphylococcus aureus) requires Contact Precautions to prevent
transmission to other patients and healthcare workers. This includes wearing gloves and gown for all
interactions, using dedicated equipment, and placing the client in a private room if possible. Standard
precautions alone (A) are insufficient for known MRSA. Obtaining a culture (B) may be appropriate but
should not delay implementing precautions. Vancomycin (D) requires a provider order and culture
sensitivity results.
Question 8
