WGU D446 Adult Health II |PA |Pre
Assessment -Solved
1. A client with left-sided heart failure develops increasing dyspnea and bilateral
crackles. Which intervention should the nurse prioritize?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Encourage ambulation
D. Place the client flat in bed
2. Which finding is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Orthopnea
C. Jugular venous distention
D. Pink frothy sputum
3. A client receiving furosemide for heart failure is at greatest risk for which
electrolyte imbalance?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
4. A client reports crushing substernal chest pain radiating to the left arm and
diaphoresis. Which laboratory result is most specific for myocardial injury?
A. BNP
B. Troponin
C. D-dimer
D. Creatinine
5. A client with COPD has an oxygen saturation of 86%. Which prescribed
intervention should the nurse anticipate?
A. Withhold oxygen
B. Administer controlled oxygen therapy
C. Place the client in Trendelenburg position
D. Encourage rapid deep breathing
6. Which assessment finding is most concerning in a client experiencing an acute
asthma exacerbation?
A. Mild expiratory wheezing
,B. Productive cough
C. Diminishing breath sounds with severe respiratory distress
D. Respiratory rate of 20/min
7. A client is suspected of having a pulmonary embolism. Which finding requires
immediate attention?
A. Sudden dyspnea and pleuritic chest pain
B. Gradual weight gain
C. Bilateral ankle edema
D. Productive cough for 3 weeks
8. A client with pneumonia has an oxygen saturation of 88%, respiratory rate of
30/min, and increasing confusion. What should the nurse do first?
A. Obtain a dietary history
B. Apply oxygen as prescribed
C. Encourage oral fluids
D. Assist with bathing
9. Which finding is expected in a client with diabetic ketoacidosis (DKA)?
A. Kussmaul respirations
B. Bradycardia with hypertension
C. Severe hypoglycemia
D. Respiratory alkalosis
10. Which intervention is the priority during initial treatment of DKA?
A. Administer IV isotonic fluid as prescribed
B. Restrict fluids
C. Administer oral glucose
D. Encourage exercise
11. A client with Addison disease is at risk for which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypercalcemia
12. Which assessment finding is associated with Cushing syndrome?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Central obesity and moon-shaped face
D. Severe dehydration
, 13. A client with SIADH is most likely to develop:
A. Hypernatremia
B. Hyponatremia
C. Hyperkalemia
D. Hypercalcemia
14. Which finding is expected in diabetes insipidus?
A. Concentrated urine
B. Low urine output
C. Excessive dilute urine
D. Fluid retention
15. A client develops sudden facial drooping and weakness of the right arm. What is
the nurse's priority?
A. Give the client food
B. Determine the time symptoms began
C. Encourage ambulation
D. Place the client in a warm bath
16. Which finding is most consistent with increased intracranial pressure?
A. Decreased blood pressure
B. Improved level of consciousness
C. Decreasing level of consciousness
D. Increased urine output
17. A client with Parkinson disease is experiencing difficulty initiating movement.
Which intervention is appropriate?
A. Encourage deliberate, larger movements
B. Keep the client on strict bed rest
C. Discourage assistive devices
D. Provide rapid verbal instructions
18. Which assessment finding is characteristic of Guillain-Barré syndrome?
A. Ascending muscle weakness
B. Unilateral facial paralysis only
C. Increased muscle strength
D. Hyperactive bowel sounds
19. A client with a spinal cord injury develops severe hypertension, headache, and
diaphoresis. What complication should the nurse suspect?
A. Hypoglycemia
Assessment -Solved
1. A client with left-sided heart failure develops increasing dyspnea and bilateral
crackles. Which intervention should the nurse prioritize?
A. Encourage oral fluids
B. Place the client in high-Fowler's position
C. Encourage ambulation
D. Place the client flat in bed
2. Which finding is most characteristic of right-sided heart failure?
A. Pulmonary crackles
B. Orthopnea
C. Jugular venous distention
D. Pink frothy sputum
3. A client receiving furosemide for heart failure is at greatest risk for which
electrolyte imbalance?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypermagnesemia
4. A client reports crushing substernal chest pain radiating to the left arm and
diaphoresis. Which laboratory result is most specific for myocardial injury?
A. BNP
B. Troponin
C. D-dimer
D. Creatinine
5. A client with COPD has an oxygen saturation of 86%. Which prescribed
intervention should the nurse anticipate?
A. Withhold oxygen
B. Administer controlled oxygen therapy
C. Place the client in Trendelenburg position
D. Encourage rapid deep breathing
6. Which assessment finding is most concerning in a client experiencing an acute
asthma exacerbation?
A. Mild expiratory wheezing
,B. Productive cough
C. Diminishing breath sounds with severe respiratory distress
D. Respiratory rate of 20/min
7. A client is suspected of having a pulmonary embolism. Which finding requires
immediate attention?
A. Sudden dyspnea and pleuritic chest pain
B. Gradual weight gain
C. Bilateral ankle edema
D. Productive cough for 3 weeks
8. A client with pneumonia has an oxygen saturation of 88%, respiratory rate of
30/min, and increasing confusion. What should the nurse do first?
A. Obtain a dietary history
B. Apply oxygen as prescribed
C. Encourage oral fluids
D. Assist with bathing
9. Which finding is expected in a client with diabetic ketoacidosis (DKA)?
A. Kussmaul respirations
B. Bradycardia with hypertension
C. Severe hypoglycemia
D. Respiratory alkalosis
10. Which intervention is the priority during initial treatment of DKA?
A. Administer IV isotonic fluid as prescribed
B. Restrict fluids
C. Administer oral glucose
D. Encourage exercise
11. A client with Addison disease is at risk for which electrolyte imbalance?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypercalcemia
12. Which assessment finding is associated with Cushing syndrome?
A. Weight loss and hypotension
B. Bronze skin pigmentation
C. Central obesity and moon-shaped face
D. Severe dehydration
, 13. A client with SIADH is most likely to develop:
A. Hypernatremia
B. Hyponatremia
C. Hyperkalemia
D. Hypercalcemia
14. Which finding is expected in diabetes insipidus?
A. Concentrated urine
B. Low urine output
C. Excessive dilute urine
D. Fluid retention
15. A client develops sudden facial drooping and weakness of the right arm. What is
the nurse's priority?
A. Give the client food
B. Determine the time symptoms began
C. Encourage ambulation
D. Place the client in a warm bath
16. Which finding is most consistent with increased intracranial pressure?
A. Decreased blood pressure
B. Improved level of consciousness
C. Decreasing level of consciousness
D. Increased urine output
17. A client with Parkinson disease is experiencing difficulty initiating movement.
Which intervention is appropriate?
A. Encourage deliberate, larger movements
B. Keep the client on strict bed rest
C. Discourage assistive devices
D. Provide rapid verbal instructions
18. Which assessment finding is characteristic of Guillain-Barré syndrome?
A. Ascending muscle weakness
B. Unilateral facial paralysis only
C. Increased muscle strength
D. Hyperactive bowel sounds
19. A client with a spinal cord injury develops severe hypertension, headache, and
diaphoresis. What complication should the nurse suspect?
A. Hypoglycemia
