WGU D446 Adult Health II Objective
Assessment -Solved
1.
A client with acute heart failure is receiving IV furosemide. Which finding requires
the most immediate nursing intervention?
A. Urine output of 900 mL over 8 hours
B. Potassium level of 2.9 mEq/L
C. Blood pressure of 108/68 mm Hg
D. Mild decrease in peripheral edema
2.
A client with increased intracranial pressure is being monitored after a head injury.
Which finding is most concerning?
A. Headache rated 5/10
B. Blood pressure 168/58 mm Hg with widening pulse pressure
C. Heart rate 92/min
D. Temperature 37.2°C (99°F)
3.
A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which ECG
change should the nurse anticipate?
A. Prolonged QT interval
B. Peaked T waves
C. ST elevation
D. U waves
4.
A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). Which
intervention is the priority?
A. Administer IV regular insulin
B. Begin isotonic IV fluid replacement
C. Administer potassium immediately
D. Give sodium bicarbonate routinely
5.
A client with a suspected stroke suddenly develops difficulty speaking and right-
sided weakness. What should the nurse do first?
A. Give oral aspirin
B. Determine the exact time symptoms began
C. Place the client in Trendelenburg position
D. Encourage ambulation
6.
A client taking warfarin for atrial fibrillation has an INR of 5.8. Which action is most
,appropriate?
A. Administer the scheduled dose
B. Hold the medication and notify the provider
C. Give an additional dose
D. Encourage foods high in vitamin K immediately
7.
A client with Parkinson disease is prescribed carbidopa-levodopa. Which statement
indicates correct understanding?
A. “I should stop taking it when my tremors improve.”
B. “This medication can improve my movement symptoms.”
C. “I should take extra doses whenever I feel stiff.”
D. “This medication permanently cures Parkinson disease.”
8.
A client with a spinal cord injury develops severe hypertension, headache, flushing,
and sweating above the level of injury. Which complication should the nurse
suspect?
A. Neurogenic shock
B. Autonomic dysreflexia
C. Hypovolemic shock
D. Septic shock
9.
A client with chronic obstructive pulmonary disease (COPD) has increasing dyspnea
and an oxygen saturation of 84%. Which action should the nurse take first?
A. Place the client in high-Fowler position
B. Encourage the client to lie flat
C. Restrict fluids
D. Administer a sedative
10.
A client with peripheral arterial disease reports severe leg pain when walking that
improves with rest. Which teaching is appropriate?
A. Elevate the legs above the heart
B. Use a heating pad on the legs
C. Participate in a prescribed walking program
D. Cross the legs when sitting
11.
A client with acute kidney injury has a urine output of 15 mL/hr for 3 consecutive
hours. Which action is the priority?
A. Document the finding as expected
B. Notify the healthcare provider
C. Encourage high-potassium foods
D. Administer an NSAID
12.
, A client with Addison disease is experiencing weakness, hypotension, and
hyperkalemia. Which medication should the nurse anticipate administering during
an adrenal crisis?
A. Hydrocortisone
B. Levothyroxine
C. Methimazole
D. Desmopressin
13.
A client with hyperthyroidism develops fever, severe tachycardia, agitation, and
vomiting. Which complication does the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Addisonian crisis
D. Hypoglycemia
14.
A client with hypothyroidism becomes extremely lethargic, hypothermic, and
bradycardic. Which complication is most likely?
A. Thyroid storm
B. Myxedema coma
C. Diabetic ketoacidosis
D. Pheochromocytoma
15.
A client with acute pancreatitis reports severe epigastric pain radiating to the back.
Which laboratory value would support this diagnosis?
A. Decreased lipase
B. Increased lipase
C. Decreased bilirubin
D. Increased hemoglobin
16.
A client with cirrhosis develops confusion and asterixis. Which medication does the
nurse anticipate?
A. Lactulose
B. Furosemide only
C. Warfarin
D. Calcium carbonate
17.
A client with liver disease is receiving lactulose. Which finding indicates the
medication is producing the desired effect?
A. One hard stool every 3 days
B. Two to three soft stools daily with improved mentation
C. Complete absence of bowel movements
D. Severe abdominal distention
Assessment -Solved
1.
A client with acute heart failure is receiving IV furosemide. Which finding requires
the most immediate nursing intervention?
A. Urine output of 900 mL over 8 hours
B. Potassium level of 2.9 mEq/L
C. Blood pressure of 108/68 mm Hg
D. Mild decrease in peripheral edema
2.
A client with increased intracranial pressure is being monitored after a head injury.
Which finding is most concerning?
A. Headache rated 5/10
B. Blood pressure 168/58 mm Hg with widening pulse pressure
C. Heart rate 92/min
D. Temperature 37.2°C (99°F)
3.
A client with chronic kidney disease has a potassium level of 6.4 mEq/L. Which ECG
change should the nurse anticipate?
A. Prolonged QT interval
B. Peaked T waves
C. ST elevation
D. U waves
4.
A client with diabetes mellitus is experiencing diabetic ketoacidosis (DKA). Which
intervention is the priority?
A. Administer IV regular insulin
B. Begin isotonic IV fluid replacement
C. Administer potassium immediately
D. Give sodium bicarbonate routinely
5.
A client with a suspected stroke suddenly develops difficulty speaking and right-
sided weakness. What should the nurse do first?
A. Give oral aspirin
B. Determine the exact time symptoms began
C. Place the client in Trendelenburg position
D. Encourage ambulation
6.
A client taking warfarin for atrial fibrillation has an INR of 5.8. Which action is most
,appropriate?
A. Administer the scheduled dose
B. Hold the medication and notify the provider
C. Give an additional dose
D. Encourage foods high in vitamin K immediately
7.
A client with Parkinson disease is prescribed carbidopa-levodopa. Which statement
indicates correct understanding?
A. “I should stop taking it when my tremors improve.”
B. “This medication can improve my movement symptoms.”
C. “I should take extra doses whenever I feel stiff.”
D. “This medication permanently cures Parkinson disease.”
8.
A client with a spinal cord injury develops severe hypertension, headache, flushing,
and sweating above the level of injury. Which complication should the nurse
suspect?
A. Neurogenic shock
B. Autonomic dysreflexia
C. Hypovolemic shock
D. Septic shock
9.
A client with chronic obstructive pulmonary disease (COPD) has increasing dyspnea
and an oxygen saturation of 84%. Which action should the nurse take first?
A. Place the client in high-Fowler position
B. Encourage the client to lie flat
C. Restrict fluids
D. Administer a sedative
10.
A client with peripheral arterial disease reports severe leg pain when walking that
improves with rest. Which teaching is appropriate?
A. Elevate the legs above the heart
B. Use a heating pad on the legs
C. Participate in a prescribed walking program
D. Cross the legs when sitting
11.
A client with acute kidney injury has a urine output of 15 mL/hr for 3 consecutive
hours. Which action is the priority?
A. Document the finding as expected
B. Notify the healthcare provider
C. Encourage high-potassium foods
D. Administer an NSAID
12.
, A client with Addison disease is experiencing weakness, hypotension, and
hyperkalemia. Which medication should the nurse anticipate administering during
an adrenal crisis?
A. Hydrocortisone
B. Levothyroxine
C. Methimazole
D. Desmopressin
13.
A client with hyperthyroidism develops fever, severe tachycardia, agitation, and
vomiting. Which complication does the nurse suspect?
A. Myxedema coma
B. Thyroid storm
C. Addisonian crisis
D. Hypoglycemia
14.
A client with hypothyroidism becomes extremely lethargic, hypothermic, and
bradycardic. Which complication is most likely?
A. Thyroid storm
B. Myxedema coma
C. Diabetic ketoacidosis
D. Pheochromocytoma
15.
A client with acute pancreatitis reports severe epigastric pain radiating to the back.
Which laboratory value would support this diagnosis?
A. Decreased lipase
B. Increased lipase
C. Decreased bilirubin
D. Increased hemoglobin
16.
A client with cirrhosis develops confusion and asterixis. Which medication does the
nurse anticipate?
A. Lactulose
B. Furosemide only
C. Warfarin
D. Calcium carbonate
17.
A client with liver disease is receiving lactulose. Which finding indicates the
medication is producing the desired effect?
A. One hard stool every 3 days
B. Two to three soft stools daily with improved mentation
C. Complete absence of bowel movements
D. Severe abdominal distention
