NCLEXRN Adult Health Nursing Questions and
Explanations – WGU D120 OBJECTIVE
ASSESSMENT ACTUAL EXAM STUDY GUIDE
2025/2026 COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES || 100% GUARANTEED PASS
<LATEST VERSION>
NCLEX-RN Adult Health Nursing: 100 Questions & Rationales
1. A client with heart failure is prescribed Furosemide (Lasix) 40 mg IV twice daily. Which
finding indicates to the nurse that the medication is effective?
A. Increased urine output ✓
B. Decreased heart rate
C. Increased blood pressure
D. Decreased respiratory rate
Rationale: Furosemide is a loop diuretic. Its primary therapeutic effect in heart failure is to
promote the excretion of fluid (diuresis), which reduces preload and edema. An increased urine
output is the most direct and immediate sign of its effectiveness.
2. When assessing a client with a new diagnosis of Addison's disease, the nurse would expect
to find:
A. Weight gain and moon face
B. Hypertension and hyperglycemia
C. Hyperpigmentation and hypotension ✓
D. Tachycardia and exophthalmos
Rationale: Addison's disease involves adrenal insufficiency, leading to a deficiency of
aldosterone and cortisol. Aldosterone deficiency causes hyponatremia and hypotension, while
cortisol deficiency can cause hyperpigmentation due to increased ACTH. Weight gain and moon
face (A) are seen in Cushing's syndrome. Hypertension (B) is also seen in Cushing's. Tachycardia
and exophthalmos (D) are associated with hyperthyroidism.
,3. A client is receiving a unit of packed red blood cells. Fifteen minutes after the transfusion
begins, the client reports chills, low back pain, and anxiety. What is the nurse's priority
action?
A. Slow the transfusion rate and monitor vital signs.
B. Administer an antihistamine as prescribed.
C. Stop the transfusion and keep the IV line open with normal saline. ✓
D. Check the client's blood type and crossmatch.
Rationale: The symptoms (chills, low back pain, anxiety) are classic signs of an acute hemolytic
transfusion reaction, often due to ABO incompatibility. This is a medical emergency. The
immediate priority is to stop the transfusion to prevent further infusion of the incompatible
blood and to maintain IV access with normal saline for emergency medication administration.
4. The nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which
medication should the nurse anticipate administering?
A. Spironolactone (Aldactone)
B. Sodium polystyrene sulfonate (Kayexalate) ✓
C. Potassium Chloride (K-Dur)
D. Hydrochlorothiazide (Microzide)
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, a dangerous condition that
can lead to fatal cardiac dysrhythmias. Kayexalate is a cation-exchange resin that helps remove
potassium from the body through the gastrointestinal tract. Spironolactone (A) is a potassium-
sparing diuretic and would worsen the condition. Potassium Chloride (C) would be lethal.
Hydrochlorothiazide (D) is a thiazide diuretic that can cause hypokalemia.
5. A client with a head injury has clear fluid draining from the nose. Which action should the
nurse take first?
A. Test the fluid for glucose.
B. Suction the nose to maintain patency.
C. Place the client in a semi-Fowler's position. ✓
D. Pack the nostrils with sterile gauze.
Rationale: Clear drainage from the nose or ear after a head injury could be cerebrospinal fluid
(CSF) leakage, indicating a skull fracture. Placing the client in a semi-Fowler's position helps
reduce intracranial pressure and the flow of CSF. Testing for glucose (A) is not definitive and is
no longer recommended as nasal secretions can also contain glucose. Suctioning (B) or packing
the nose (D) is contraindicated as it could introduce bacteria into the CNS, leading to meningitis.
6. A client with Crohn's disease is admitted with a possible bowel obstruction. The nurse
would expect the client's stool to appear as:
A. Clay-colored
,B. Bright red and bloody
C. Fatty and foul-smelling (steatorrhea)
D. Liquid with mucus and pus ✓
Rationale: Crohn's disease is characterized by transmural inflammation, often leading to
fistulas, fissures, and abscesses. The stool is typically chronic, watery diarrhea and may contain
mucus and pus due to the inflammatory process. Clay-colored stool (A) indicates a lack of bile,
as in biliary obstruction. Bright red blood (B) is more typical of lower GI bleeds or ulcerative
colitis. Steatorrhea (C) is seen in malabsorption syndromes like cystic fibrosis or celiac disease.
7. The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about
breathing techniques. Which instruction is most important?
A. "Use pursed-lip breathing during periods of dyspnea." ✓
B. "Take quick, shallow breaths to conserve energy."
C. "Breathe in through your mouth and out through your nose."
D. "Lie flat on your back to practice deep breathing."
Rationale: Pursed-lip breathing helps slow expiration, prevent collapse of small airways, and
improve ventilation by maintaining positive airway pressure. This is a cornerstone technique for
managing dyspnea in COPD. Quick, shallow breaths (B) increase the work of breathing and do
not improve gas exchange. Breathing in through the mouth (C) can dry airways. Lying flat (D)
compromises lung expansion in a client with COPD.
8. A client with myasthenia gravis reports increased difficulty swallowing and double vision.
The nurse recognizes these as signs of:
A. An adverse reaction to Neostigmine (Prostigmin)
B. A cholinergic crisis
C. A myasthenic crisis ✓
D. Disease remission
Rationale: Myasthenic crisis is an exacerbation of the disease characterized by severe muscle
weakness, including respiratory, bulbar (swallowing, speaking), and ocular muscles. It is often
triggered by infection, stress, or under-medication. Cholinergic crisis (B) is caused by
overmedication with cholinesterase inhibitors and includes symptoms like excessive salivation,
lacrimation, and bradycardia.
9. A client is scheduled for a colonoscopy. Which client statement indicates that the bowel
preparation teaching has been effective?
A. "I should have a solid breakfast the day before the procedure."
B. "My stools should be clear and liquid before the procedure." ✓
C. "I can have black coffee the morning of the procedure."
D. "I will take my daily warfarin the morning of the procedure."
, Rationale: The goal of bowel prep is to clear the colon of all solid material to allow for optimal
visualization. Stool that is clear and liquid (yellow-tinged is acceptable) indicates a clean colon.
Clients must be on a clear liquid diet and NPO before the procedure (A and C are incorrect).
Anticoagulants like warfarin (D) are typically held prior to procedures to reduce the risk of
bleeding.
10. The nurse is assessing a client with pancreatitis. Which finding is the priority concern?
A. Steatorrhea
B. Severe, radiating abdominal pain
C. Serum calcium level of 7.8 mg/dL ✓
D. Elevated serum amylase
Rationale: While pain (B) and elevated amylase (D) are hallmark signs of pancreatitis,
hypocalcemia (low serum calcium) is a serious complication that can lead to tetany, seizures,
and cardiac dysrhythmias. It indicates severe, necrotizing pancreatitis and is a sign of poor
prognosis. This requires immediate intervention.
11. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus.
The nurse suspects:
A. Delirium tremens
B. Korsakoff's psychosis
C. Wernicke's encephalopathy ✓
D. Hepatic encephalopathy
Rationale: Wernicke's encephalopathy is an acute neurological condition caused by thiamine
(B1) deficiency, common in alcoholism. The classic triad is confusion, ataxia (unsteady gait), and
nystagmus (involuntary eye movements). It is a medical emergency requiring immediate
thiamine administration.
12. A client with type 1 diabetes has a blood glucose level of 55 mg/dL. The client is conscious
and alert. What should the nurse administer?
A. 1 mg of Glucagon IM
B. 4 oz of orange juice ✓
C. 10 units of regular insulin
D. A carbohydrate-free diet
Rationale: For a conscious client with hypoglycemia, the rule of "15-15" applies: administer 15
grams of a fast-acting carbohydrate (like 4 oz of orange juice) and recheck blood glucose in 15
minutes. Glucagon (A) is for unconscious clients who cannot swallow. Insulin (C) would lower
the blood glucose further, which is dangerous. A carb-free diet (D) is inappropriate.
13. When caring for a client with a chest tube connected to a water-seal drainage system, the
nurse observes continuous bubbling in the water-seal chamber. What is the appropriate
Explanations – WGU D120 OBJECTIVE
ASSESSMENT ACTUAL EXAM STUDY GUIDE
2025/2026 COMPLETE QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES || 100% GUARANTEED PASS
<LATEST VERSION>
NCLEX-RN Adult Health Nursing: 100 Questions & Rationales
1. A client with heart failure is prescribed Furosemide (Lasix) 40 mg IV twice daily. Which
finding indicates to the nurse that the medication is effective?
A. Increased urine output ✓
B. Decreased heart rate
C. Increased blood pressure
D. Decreased respiratory rate
Rationale: Furosemide is a loop diuretic. Its primary therapeutic effect in heart failure is to
promote the excretion of fluid (diuresis), which reduces preload and edema. An increased urine
output is the most direct and immediate sign of its effectiveness.
2. When assessing a client with a new diagnosis of Addison's disease, the nurse would expect
to find:
A. Weight gain and moon face
B. Hypertension and hyperglycemia
C. Hyperpigmentation and hypotension ✓
D. Tachycardia and exophthalmos
Rationale: Addison's disease involves adrenal insufficiency, leading to a deficiency of
aldosterone and cortisol. Aldosterone deficiency causes hyponatremia and hypotension, while
cortisol deficiency can cause hyperpigmentation due to increased ACTH. Weight gain and moon
face (A) are seen in Cushing's syndrome. Hypertension (B) is also seen in Cushing's. Tachycardia
and exophthalmos (D) are associated with hyperthyroidism.
,3. A client is receiving a unit of packed red blood cells. Fifteen minutes after the transfusion
begins, the client reports chills, low back pain, and anxiety. What is the nurse's priority
action?
A. Slow the transfusion rate and monitor vital signs.
B. Administer an antihistamine as prescribed.
C. Stop the transfusion and keep the IV line open with normal saline. ✓
D. Check the client's blood type and crossmatch.
Rationale: The symptoms (chills, low back pain, anxiety) are classic signs of an acute hemolytic
transfusion reaction, often due to ABO incompatibility. This is a medical emergency. The
immediate priority is to stop the transfusion to prevent further infusion of the incompatible
blood and to maintain IV access with normal saline for emergency medication administration.
4. The nurse is caring for a client with a serum potassium level of 6.2 mEq/L. Which
medication should the nurse anticipate administering?
A. Spironolactone (Aldactone)
B. Sodium polystyrene sulfonate (Kayexalate) ✓
C. Potassium Chloride (K-Dur)
D. Hydrochlorothiazide (Microzide)
Rationale: A potassium level of 6.2 mEq/L indicates hyperkalemia, a dangerous condition that
can lead to fatal cardiac dysrhythmias. Kayexalate is a cation-exchange resin that helps remove
potassium from the body through the gastrointestinal tract. Spironolactone (A) is a potassium-
sparing diuretic and would worsen the condition. Potassium Chloride (C) would be lethal.
Hydrochlorothiazide (D) is a thiazide diuretic that can cause hypokalemia.
5. A client with a head injury has clear fluid draining from the nose. Which action should the
nurse take first?
A. Test the fluid for glucose.
B. Suction the nose to maintain patency.
C. Place the client in a semi-Fowler's position. ✓
D. Pack the nostrils with sterile gauze.
Rationale: Clear drainage from the nose or ear after a head injury could be cerebrospinal fluid
(CSF) leakage, indicating a skull fracture. Placing the client in a semi-Fowler's position helps
reduce intracranial pressure and the flow of CSF. Testing for glucose (A) is not definitive and is
no longer recommended as nasal secretions can also contain glucose. Suctioning (B) or packing
the nose (D) is contraindicated as it could introduce bacteria into the CNS, leading to meningitis.
6. A client with Crohn's disease is admitted with a possible bowel obstruction. The nurse
would expect the client's stool to appear as:
A. Clay-colored
,B. Bright red and bloody
C. Fatty and foul-smelling (steatorrhea)
D. Liquid with mucus and pus ✓
Rationale: Crohn's disease is characterized by transmural inflammation, often leading to
fistulas, fissures, and abscesses. The stool is typically chronic, watery diarrhea and may contain
mucus and pus due to the inflammatory process. Clay-colored stool (A) indicates a lack of bile,
as in biliary obstruction. Bright red blood (B) is more typical of lower GI bleeds or ulcerative
colitis. Steatorrhea (C) is seen in malabsorption syndromes like cystic fibrosis or celiac disease.
7. The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about
breathing techniques. Which instruction is most important?
A. "Use pursed-lip breathing during periods of dyspnea." ✓
B. "Take quick, shallow breaths to conserve energy."
C. "Breathe in through your mouth and out through your nose."
D. "Lie flat on your back to practice deep breathing."
Rationale: Pursed-lip breathing helps slow expiration, prevent collapse of small airways, and
improve ventilation by maintaining positive airway pressure. This is a cornerstone technique for
managing dyspnea in COPD. Quick, shallow breaths (B) increase the work of breathing and do
not improve gas exchange. Breathing in through the mouth (C) can dry airways. Lying flat (D)
compromises lung expansion in a client with COPD.
8. A client with myasthenia gravis reports increased difficulty swallowing and double vision.
The nurse recognizes these as signs of:
A. An adverse reaction to Neostigmine (Prostigmin)
B. A cholinergic crisis
C. A myasthenic crisis ✓
D. Disease remission
Rationale: Myasthenic crisis is an exacerbation of the disease characterized by severe muscle
weakness, including respiratory, bulbar (swallowing, speaking), and ocular muscles. It is often
triggered by infection, stress, or under-medication. Cholinergic crisis (B) is caused by
overmedication with cholinesterase inhibitors and includes symptoms like excessive salivation,
lacrimation, and bradycardia.
9. A client is scheduled for a colonoscopy. Which client statement indicates that the bowel
preparation teaching has been effective?
A. "I should have a solid breakfast the day before the procedure."
B. "My stools should be clear and liquid before the procedure." ✓
C. "I can have black coffee the morning of the procedure."
D. "I will take my daily warfarin the morning of the procedure."
, Rationale: The goal of bowel prep is to clear the colon of all solid material to allow for optimal
visualization. Stool that is clear and liquid (yellow-tinged is acceptable) indicates a clean colon.
Clients must be on a clear liquid diet and NPO before the procedure (A and C are incorrect).
Anticoagulants like warfarin (D) are typically held prior to procedures to reduce the risk of
bleeding.
10. The nurse is assessing a client with pancreatitis. Which finding is the priority concern?
A. Steatorrhea
B. Severe, radiating abdominal pain
C. Serum calcium level of 7.8 mg/dL ✓
D. Elevated serum amylase
Rationale: While pain (B) and elevated amylase (D) are hallmark signs of pancreatitis,
hypocalcemia (low serum calcium) is a serious complication that can lead to tetany, seizures,
and cardiac dysrhythmias. It indicates severe, necrotizing pancreatitis and is a sign of poor
prognosis. This requires immediate intervention.
11. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus.
The nurse suspects:
A. Delirium tremens
B. Korsakoff's psychosis
C. Wernicke's encephalopathy ✓
D. Hepatic encephalopathy
Rationale: Wernicke's encephalopathy is an acute neurological condition caused by thiamine
(B1) deficiency, common in alcoholism. The classic triad is confusion, ataxia (unsteady gait), and
nystagmus (involuntary eye movements). It is a medical emergency requiring immediate
thiamine administration.
12. A client with type 1 diabetes has a blood glucose level of 55 mg/dL. The client is conscious
and alert. What should the nurse administer?
A. 1 mg of Glucagon IM
B. 4 oz of orange juice ✓
C. 10 units of regular insulin
D. A carbohydrate-free diet
Rationale: For a conscious client with hypoglycemia, the rule of "15-15" applies: administer 15
grams of a fast-acting carbohydrate (like 4 oz of orange juice) and recheck blood glucose in 15
minutes. Glucagon (A) is for unconscious clients who cannot swallow. Insulin (C) would lower
the blood glucose further, which is dangerous. A carb-free diet (D) is inappropriate.
13. When caring for a client with a chest tube connected to a water-seal drainage system, the
nurse observes continuous bubbling in the water-seal chamber. What is the appropriate
