WGU D446 Adult Health 2 questions
with complete solutions
A 55-year-old patient with a history of smoking is scheduled for elective surgery. Which
preoperative assessment finding is most concerning to the nurse? Rationale: may indicate mild
hypoxemia, especially concerning in a patient with a history of smoking, as it could impact
oxygenation during surgery. The nurse should report this finding for further evaluation. Other
options are within normal limits and less concerning. - ANS ✔✔Pulse oximetry reading of 92%
During preoperative teaching, a patient expresses fear about anesthesia. Which response by the
nurse best addresses the patient's concern? Rationale: This response encourages the patient to
verbalize specific fears, allowing the nurse to provide accurate information and emotional
support. It's a patient-centered approach, addressing individual concerns rather than providing
general reassurance. - ANS ✔✔"Tell me more about what concerns you about the anesthesia."
The nurse is in the operating room and notices that a sterile field may have been contaminated.
What is the nurse's best action? Rationale: Maintaining a sterile environment is crucial to
prevent infection. The nurse must inform the surgical team immediately to ensure corrective
actions are taken. Ignoring it or not notifying others compromises patient safety. - ANS
✔✔Immediately inform the surgical team.
A patient in the post-anesthesia care unit (PACU) has shallow, irregular breathing. What should
be the nurse's priority intervention? Rationale: Encouraging deep breathing helps prevent
hypoventilation and increases oxygenation, addressing the shallow breathing. Other options,
while appropriate, are secondary to first attempting to improve the patient's breathing pattern.
- ANS ✔✔Stimulate the patient to encourage deep breathing.
A postoperative patient reports pain at the incision site. Which is the most appropriate nursing
intervention? Rationale: Postoperative pain is expected, and the nurse should administer pain
relief as prescribed to promote comfort and facilitate healing. Monitoring alone is insufficient,
and massage could disrupt the incision. - ANS ✔✔Provide prescribed analgesics as needed.
,The nurse is preparing to administer preoperative medication. Which of the following should
the nurse verify before administration? Rationale: Ensuring the patient has been NPO (nothing
by mouth) before administering preoperative medication reduces the risk of aspiration during
anesthesia. The other factors are less directly related to preoperative medication safety. - ANS
✔✔Last oral intake
The nurse is educating a patient on the use of opioids postoperatively. Which of the following
should the nurse emphasize? Rationale: Constipation is a common side effect of opioids. The
nurse should advise fluid intake to prevent this. Other options are inaccurate or incomplete
instructions. - ANS ✔✔Drink plenty of fluids to prevent constipation.
A postoperative patient needs assistance ambulating. Which team member should the nurse
collaborate with to ensure safe ambulation? Rationale: Physical therapists specialize in mobility
and can assist the nurse in ambulating the patient safely, which can prevent falls and encourage
recovery. - ANS ✔✔Physical therapist
A patient's surgical wound shows signs of infection. The nurse should consult which healthcare
professional first? Rationale: responsible for managing surgical site infections and can make
decisions regarding wound care and antibiotic therapy. - ANS ✔✔Surgeon
When providing discharge instructions to a postoperative patient, which topic should the nurse
prioritize? Rationale: Effective wound care is essential in preventing infection and promoting
healing, which is critical in the immediate postoperative period. This takes priority in discharge
education. - ANS ✔✔Proper wound care techniques
A postoperative patient develops sudden chest pain and shortness of breath. Which action
should the nurse take first? Rationale: Chest pain and shortness of breath are signs of possible
pulmonary embolism, a medical emergency. Oxygen administration and notifying the team
immediately are crucial. Elevating the bed may follow after these primary actions. - ANS
✔✔Administer oxygen and call for immediate assistance.
, The nurse notices excessive bleeding from a postoperative patient's surgical site. What is the
nurse's priority intervention?Rationale: Apply pressure the bleeding site helps control bleeding
temporarily while waiting for further instructions. Prompt communication with the healthcare
provider is essential to prevent potential hemorrhage. - ANS ✔✔Apply pressure to the site and
notify the healthcare provider.
A patient reports inadequate pain relief 30 minutes after receiving a prescribed dose of
morphine. What should the nurse do next?Rationale: If pain relief is inadequate, the nurse
should notify the healthcare provider for an alternative approach to manage the patient's pain
effectively. Simply re-evaluating or teaching relaxation alone may not sufficiently address severe
pain. - ANS ✔✔Call the healthcare provider for additional pain management orders
During postoperative rounds, a nurse observes that a patient's pain level has increased. Which
nursing intervention would be most appropriate?Rationale: Assessing pain and providing
appropriate pharmacologic intervention is essential for effective pain management.
Nonpharmacologic methods can supplement but are not replacements for prescribed analgesics
in cases of increased pain. - ANS ✔✔Assess the patient's pain and administer additional
prescribed analgesics as needed.
In the PACU, a patient begins to snore loudly and has decreased oxygen saturation. What should
the nurse do first?Rationale: Snoring and decreased oxygen saturation in a postoperative
patient may be due to partial airway obstruction. Elevating the head opens the airway, often
correcting mild obstruction. Further interventions, like an oral airway, are considered if
elevation is ineffective. - ANS ✔✔Elevate the patient's head.
A patient who had abdominal surgery 24 hours ago has a low urine output of 20 mL/hour. What
is the nurse's priority action?Rationale: Low urine output after surgery may indicate
hypovolemia or renal complications. The nurse should promptly notify the healthcare provider
for evaluation and management, as increasing IV fluids without provider instructions is not
within nursing scope in this context. - ANS ✔✔Notify the healthcare provider.
The nurse assesses that a postoperative patient is hypotensive, tachycardic, and has cold,
clammy skin. Which condition should the nurse suspect?Rationale: Hypotension, tachycardia,
with complete solutions
A 55-year-old patient with a history of smoking is scheduled for elective surgery. Which
preoperative assessment finding is most concerning to the nurse? Rationale: may indicate mild
hypoxemia, especially concerning in a patient with a history of smoking, as it could impact
oxygenation during surgery. The nurse should report this finding for further evaluation. Other
options are within normal limits and less concerning. - ANS ✔✔Pulse oximetry reading of 92%
During preoperative teaching, a patient expresses fear about anesthesia. Which response by the
nurse best addresses the patient's concern? Rationale: This response encourages the patient to
verbalize specific fears, allowing the nurse to provide accurate information and emotional
support. It's a patient-centered approach, addressing individual concerns rather than providing
general reassurance. - ANS ✔✔"Tell me more about what concerns you about the anesthesia."
The nurse is in the operating room and notices that a sterile field may have been contaminated.
What is the nurse's best action? Rationale: Maintaining a sterile environment is crucial to
prevent infection. The nurse must inform the surgical team immediately to ensure corrective
actions are taken. Ignoring it or not notifying others compromises patient safety. - ANS
✔✔Immediately inform the surgical team.
A patient in the post-anesthesia care unit (PACU) has shallow, irregular breathing. What should
be the nurse's priority intervention? Rationale: Encouraging deep breathing helps prevent
hypoventilation and increases oxygenation, addressing the shallow breathing. Other options,
while appropriate, are secondary to first attempting to improve the patient's breathing pattern.
- ANS ✔✔Stimulate the patient to encourage deep breathing.
A postoperative patient reports pain at the incision site. Which is the most appropriate nursing
intervention? Rationale: Postoperative pain is expected, and the nurse should administer pain
relief as prescribed to promote comfort and facilitate healing. Monitoring alone is insufficient,
and massage could disrupt the incision. - ANS ✔✔Provide prescribed analgesics as needed.
,The nurse is preparing to administer preoperative medication. Which of the following should
the nurse verify before administration? Rationale: Ensuring the patient has been NPO (nothing
by mouth) before administering preoperative medication reduces the risk of aspiration during
anesthesia. The other factors are less directly related to preoperative medication safety. - ANS
✔✔Last oral intake
The nurse is educating a patient on the use of opioids postoperatively. Which of the following
should the nurse emphasize? Rationale: Constipation is a common side effect of opioids. The
nurse should advise fluid intake to prevent this. Other options are inaccurate or incomplete
instructions. - ANS ✔✔Drink plenty of fluids to prevent constipation.
A postoperative patient needs assistance ambulating. Which team member should the nurse
collaborate with to ensure safe ambulation? Rationale: Physical therapists specialize in mobility
and can assist the nurse in ambulating the patient safely, which can prevent falls and encourage
recovery. - ANS ✔✔Physical therapist
A patient's surgical wound shows signs of infection. The nurse should consult which healthcare
professional first? Rationale: responsible for managing surgical site infections and can make
decisions regarding wound care and antibiotic therapy. - ANS ✔✔Surgeon
When providing discharge instructions to a postoperative patient, which topic should the nurse
prioritize? Rationale: Effective wound care is essential in preventing infection and promoting
healing, which is critical in the immediate postoperative period. This takes priority in discharge
education. - ANS ✔✔Proper wound care techniques
A postoperative patient develops sudden chest pain and shortness of breath. Which action
should the nurse take first? Rationale: Chest pain and shortness of breath are signs of possible
pulmonary embolism, a medical emergency. Oxygen administration and notifying the team
immediately are crucial. Elevating the bed may follow after these primary actions. - ANS
✔✔Administer oxygen and call for immediate assistance.
, The nurse notices excessive bleeding from a postoperative patient's surgical site. What is the
nurse's priority intervention?Rationale: Apply pressure the bleeding site helps control bleeding
temporarily while waiting for further instructions. Prompt communication with the healthcare
provider is essential to prevent potential hemorrhage. - ANS ✔✔Apply pressure to the site and
notify the healthcare provider.
A patient reports inadequate pain relief 30 minutes after receiving a prescribed dose of
morphine. What should the nurse do next?Rationale: If pain relief is inadequate, the nurse
should notify the healthcare provider for an alternative approach to manage the patient's pain
effectively. Simply re-evaluating or teaching relaxation alone may not sufficiently address severe
pain. - ANS ✔✔Call the healthcare provider for additional pain management orders
During postoperative rounds, a nurse observes that a patient's pain level has increased. Which
nursing intervention would be most appropriate?Rationale: Assessing pain and providing
appropriate pharmacologic intervention is essential for effective pain management.
Nonpharmacologic methods can supplement but are not replacements for prescribed analgesics
in cases of increased pain. - ANS ✔✔Assess the patient's pain and administer additional
prescribed analgesics as needed.
In the PACU, a patient begins to snore loudly and has decreased oxygen saturation. What should
the nurse do first?Rationale: Snoring and decreased oxygen saturation in a postoperative
patient may be due to partial airway obstruction. Elevating the head opens the airway, often
correcting mild obstruction. Further interventions, like an oral airway, are considered if
elevation is ineffective. - ANS ✔✔Elevate the patient's head.
A patient who had abdominal surgery 24 hours ago has a low urine output of 20 mL/hour. What
is the nurse's priority action?Rationale: Low urine output after surgery may indicate
hypovolemia or renal complications. The nurse should promptly notify the healthcare provider
for evaluation and management, as increasing IV fluids without provider instructions is not
within nursing scope in this context. - ANS ✔✔Notify the healthcare provider.
The nurse assesses that a postoperative patient is hypotensive, tachycardic, and has cold,
clammy skin. Which condition should the nurse suspect?Rationale: Hypotension, tachycardia,
