HealthStream Jane Assessment Test
(2025/2026) | Verified Questions &
Correct Solutions | 100% Accurate –
Brand New Version
Section 1: Cardiac and Respiratory Conditions (CHF, COPD, HTN) (18 Qs)
1. A client with CHF presents with shortness of breath, orthopnea, and productive cough with
pink frothy sputum. Which hallmark signs confirm exacerbation? (Select all that apply)
A) Jugular vein distension and bilateral crackles
B) Peripheral edema and sudden weight gain >2 kg/day
C) Anxiety, restlessness, and oliguria
D) Tachycardia, tachypnea, and hypertension
E) Nagging dry cough and ascites
Answer: A, B, C, D
Rationale: These are classic pulmonary congestion and fluid overload signs in left/right-sided
CHF (HealthStream Jane CHF module 2025). E is more GI-related; monitor daily weights and
notify MD for diuretics.
2. For a client with COPD experiencing acute exacerbation, priority intervention is:
A) Administer high-flow oxygen at 6 L/min
B) Position in high-Fowler's and assess SpO2
C) Encourage pursed-lip breathing only
D) Withhold bronchodilators if HR >100
Answer: B
Rationale: Positioning reduces work of breathing; titrate O2 to maintain SpO2 88-92% to avoid
CO2 retention (2025 GOLD guidelines via HealthStream). A risks hypercapnia; C/D are
adjuncts.
3. A client with HTN reports headache and blurred vision. BP 180/110 mmHg. Initial action?
A) Administer oral antihypertensive
B) Initiate IV labetalol per protocol
, C) Reassure and monitor q4h
D) Encourage fluid restriction
Answer: B
Rationale: Hypertensive urgency/emergency requires rapid BP reduction; labetalol lowers
HR/BP safely (HealthStream HTN crisis 2025). A is for chronic; C/D delay intervention.
4. In CHF, ejection fraction (EF) <40% indicates:
A) Preserved EF (HFpEF)
B) Reduced EF (HFrEF)
C) Normal cardiac output
D) Right-sided failure only
Answer: B
Rationale: HFrEF impairs systolic function; assess via echo and anticipate ACE inhibitors/ARNI
(HealthStream cardiac assessment).
Section 2: Nursing Assessments and Interventions (16 Qs)
15. During head-to-toe assessment for a post-op client, priority finding warranting immediate
intervention is:
A) BP 130/80 mmHg
B) RR 22 breaths/min with accessory muscle use
C) Temp 98.6°F
D) Urine output 30 mL/hr
Answer: B
Rationale: Tachypnea with accessory muscles signals respiratory distress; intervene with
O2/positioning (HealthStream assessment priority 2025). Others are within norms.
16. For a client at risk for falls, evidence-based intervention includes: (Select all that apply)
A) Bed alarm and non-slip socks
B) Hourly rounding with toileting
C) Restraints as first-line
D) Dim lighting for comfort
E) Gait assessment before ambulation
Answer: A, B, E
Rationale: Fall prevention bundle reduces risk 30% (HealthStream safety 2025); C is last resort
per CMS; D increases hazards.
17. A client with suspected DKA has Kussmaul respirations. Intervention?
A) Administer bicarbonate IV
B) Prepare for fluid resuscitation and insulin drip
(2025/2026) | Verified Questions &
Correct Solutions | 100% Accurate –
Brand New Version
Section 1: Cardiac and Respiratory Conditions (CHF, COPD, HTN) (18 Qs)
1. A client with CHF presents with shortness of breath, orthopnea, and productive cough with
pink frothy sputum. Which hallmark signs confirm exacerbation? (Select all that apply)
A) Jugular vein distension and bilateral crackles
B) Peripheral edema and sudden weight gain >2 kg/day
C) Anxiety, restlessness, and oliguria
D) Tachycardia, tachypnea, and hypertension
E) Nagging dry cough and ascites
Answer: A, B, C, D
Rationale: These are classic pulmonary congestion and fluid overload signs in left/right-sided
CHF (HealthStream Jane CHF module 2025). E is more GI-related; monitor daily weights and
notify MD for diuretics.
2. For a client with COPD experiencing acute exacerbation, priority intervention is:
A) Administer high-flow oxygen at 6 L/min
B) Position in high-Fowler's and assess SpO2
C) Encourage pursed-lip breathing only
D) Withhold bronchodilators if HR >100
Answer: B
Rationale: Positioning reduces work of breathing; titrate O2 to maintain SpO2 88-92% to avoid
CO2 retention (2025 GOLD guidelines via HealthStream). A risks hypercapnia; C/D are
adjuncts.
3. A client with HTN reports headache and blurred vision. BP 180/110 mmHg. Initial action?
A) Administer oral antihypertensive
B) Initiate IV labetalol per protocol
, C) Reassure and monitor q4h
D) Encourage fluid restriction
Answer: B
Rationale: Hypertensive urgency/emergency requires rapid BP reduction; labetalol lowers
HR/BP safely (HealthStream HTN crisis 2025). A is for chronic; C/D delay intervention.
4. In CHF, ejection fraction (EF) <40% indicates:
A) Preserved EF (HFpEF)
B) Reduced EF (HFrEF)
C) Normal cardiac output
D) Right-sided failure only
Answer: B
Rationale: HFrEF impairs systolic function; assess via echo and anticipate ACE inhibitors/ARNI
(HealthStream cardiac assessment).
Section 2: Nursing Assessments and Interventions (16 Qs)
15. During head-to-toe assessment for a post-op client, priority finding warranting immediate
intervention is:
A) BP 130/80 mmHg
B) RR 22 breaths/min with accessory muscle use
C) Temp 98.6°F
D) Urine output 30 mL/hr
Answer: B
Rationale: Tachypnea with accessory muscles signals respiratory distress; intervene with
O2/positioning (HealthStream assessment priority 2025). Others are within norms.
16. For a client at risk for falls, evidence-based intervention includes: (Select all that apply)
A) Bed alarm and non-slip socks
B) Hourly rounding with toileting
C) Restraints as first-line
D) Dim lighting for comfort
E) Gait assessment before ambulation
Answer: A, B, E
Rationale: Fall prevention bundle reduces risk 30% (HealthStream safety 2025); C is last resort
per CMS; D increases hazards.
17. A client with suspected DKA has Kussmaul respirations. Intervention?
A) Administer bicarbonate IV
B) Prepare for fluid resuscitation and insulin drip
