WGU Clinical Nursing Assessment ACTUAL
QUESTIONS AND CORRECT ANSWERS PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD
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,WGU Clinical Nursing Assessment: 100 Practice Questions
1. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which finding should the nurse
report to the provider immediately?
A. Serosanguineous drainage on the dressing.
B. A temperature of 37.8°C (100.0°F).
C. A heart rate of 110/min and blood pressure of 100/60 mm Hg.
D. Absent bowel sounds in all four quadrants.
Answer: C
Rationale: Tachycardia and hypotension are early signs of hypovolemic shock, which can result from internal bleeding, a
major risk post-abdominal surgery. This is an immediate concern. A low-grade fever and serosanguineous drainage are
common post-op findings. Absent bowel sounds are expected immediately after abdominal surgery due to paralytic ileus.
2. The nurse is caring for a client with a diagnosis of heart failure. Which assessment finding indicates that the client's
condition is worsening?
A. Weight loss of 1 kg (2.2 lb) in 24 hours.
B. Crackles audible in the lung bases.
C. Urine output of 40 mL/hr.
D. Heart rate of 88/min.
Answer: B
,Rationale: Crackles in the lung bases indicate pulmonary congestion, a classic sign of worsening heart failure as fluid
backs up into the lungs. Weight loss and adequate urine output would suggest improvement. A heart rate of 88/min is
within normal limits.
3. A client is prescribed digoxin. Which assessment finding requires the nurse to hold the medication and notify the
provider?
A. Heart rate of 58/min.
B. Potassium level of 4.0 mEq/L.
C. Blood pressure of 110/70 mm Hg.
D. Heart rate of 110/min.
Answer: A
Rationale: Digoxin is a negative chronotrope (it slows the heart rate). A heart rate below 60/min in an adult is a common
reason to hold the medication. The provider must be notified. A therapeutic potassium level is important, but a low
potassium (hypokalemia) increases the risk of digoxin toxicity. A BP of 110/70 is acceptable, and a HR of 110 is not a
reason to hold the medication.
4. The nurse is teaching a client about a low-sodium diet. Which food should the client be instructed to avoid?
A. Fresh apples.
B. Canned soup.
C. Fresh chicken breast.
D. Brown rice.
, Answer: B
Rationale: Canned soups are notoriously high in sodium as it is used as a preservative and flavor enhancer. Fresh fruits,
meats, and grains are naturally low in sodium.
5. A nurse is assessing a client for signs of hypoglycemia. Which of the following findings should the nurse expect?
A. Bradycardia.
B. Warm, dry skin.
C. Increased thirst.
D. Shakiness and diaphoresis.
Answer: D
Rationale: Hypoglycemia (low blood sugar) stimulates the sympathetic nervous system, leading to symptoms such as
tremors (shakiness), diaphoresis (sweating), tachycardia, and anxiety. Bradycardia, warm dry skin, and increased thirst
are more associated with hyperglycemia.
6. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen. The nurse should monitor
for which sign of oxygen toxicity?
A. A decrease in respiratory rate.
B. A increase in somnolence.
C. A decrease in PaCO2.
D. A increase in SpO2 to 100%.
Answer: A
QUESTIONS AND CORRECT ANSWERS PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD
,WGU Clinical Nursing Assessment: 100 Practice Questions
1. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which finding should the nurse
report to the provider immediately?
A. Serosanguineous drainage on the dressing.
B. A temperature of 37.8°C (100.0°F).
C. A heart rate of 110/min and blood pressure of 100/60 mm Hg.
D. Absent bowel sounds in all four quadrants.
Answer: C
Rationale: Tachycardia and hypotension are early signs of hypovolemic shock, which can result from internal bleeding, a
major risk post-abdominal surgery. This is an immediate concern. A low-grade fever and serosanguineous drainage are
common post-op findings. Absent bowel sounds are expected immediately after abdominal surgery due to paralytic ileus.
2. The nurse is caring for a client with a diagnosis of heart failure. Which assessment finding indicates that the client's
condition is worsening?
A. Weight loss of 1 kg (2.2 lb) in 24 hours.
B. Crackles audible in the lung bases.
C. Urine output of 40 mL/hr.
D. Heart rate of 88/min.
Answer: B
,Rationale: Crackles in the lung bases indicate pulmonary congestion, a classic sign of worsening heart failure as fluid
backs up into the lungs. Weight loss and adequate urine output would suggest improvement. A heart rate of 88/min is
within normal limits.
3. A client is prescribed digoxin. Which assessment finding requires the nurse to hold the medication and notify the
provider?
A. Heart rate of 58/min.
B. Potassium level of 4.0 mEq/L.
C. Blood pressure of 110/70 mm Hg.
D. Heart rate of 110/min.
Answer: A
Rationale: Digoxin is a negative chronotrope (it slows the heart rate). A heart rate below 60/min in an adult is a common
reason to hold the medication. The provider must be notified. A therapeutic potassium level is important, but a low
potassium (hypokalemia) increases the risk of digoxin toxicity. A BP of 110/70 is acceptable, and a HR of 110 is not a
reason to hold the medication.
4. The nurse is teaching a client about a low-sodium diet. Which food should the client be instructed to avoid?
A. Fresh apples.
B. Canned soup.
C. Fresh chicken breast.
D. Brown rice.
, Answer: B
Rationale: Canned soups are notoriously high in sodium as it is used as a preservative and flavor enhancer. Fresh fruits,
meats, and grains are naturally low in sodium.
5. A nurse is assessing a client for signs of hypoglycemia. Which of the following findings should the nurse expect?
A. Bradycardia.
B. Warm, dry skin.
C. Increased thirst.
D. Shakiness and diaphoresis.
Answer: D
Rationale: Hypoglycemia (low blood sugar) stimulates the sympathetic nervous system, leading to symptoms such as
tremors (shakiness), diaphoresis (sweating), tachycardia, and anxiety. Bradycardia, warm dry skin, and increased thirst
are more associated with hyperglycemia.
6. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen. The nurse should monitor
for which sign of oxygen toxicity?
A. A decrease in respiratory rate.
B. A increase in somnolence.
C. A decrease in PaCO2.
D. A increase in SpO2 to 100%.
Answer: A
