WGU adult health 2 D446 Questions With Complete
Solutions
A client with draining skin lesions of the lover extremity is
admitted with possible Methicillin-Resistant Staphylococcus
Aureus (MRSA). Which nursing interventions should the nurse
include in the plan of care? (Select all that apply.)
Monitor the client's white blood cell count.Send wound drainage
for culture and sensitivity.Institute contact precautions for staff
and visitors.
A client with multiple sclerosis has urinary retention related to
sensorimotor details. Which action should the nurse include in
the client's plan of care?
Teach the client techniques for performing intermittent
catheterization.
An obese client with emphysema who smokes at least a pack of
cigarettes daily is admitted after experiencing a sudden increase
in dyspnea and activity intolerance. Oxygen therapy is initiated
and its determined that the client will be discharged with
oxygen. Which information is most important for the nurse to
emphasize in the discharge teaching plan?
Guidelines for oxygen use.
The nurse is caring for a client who reports a sudden, severe
headache, and facial numbness. The nurse asks the client to
smile and observes an uneven smile with facial droop the right
side and a hand grasp strength that is weaker on the right than
,the left. The client denies a recent history of headache or
trauma.Which intervention should the nurse should perform in
the immediate management of the client?
Start two large-bore IV catheters and review inclusion criteria
for IV fibrinolytic therapy.
A patient with Systemic Lupus Erythematosus (SLE) presents
with nausea, vomiting, confusion, and a history of edema.
Which of the following is the most likely cause of these
symptoms?
Uremia due to lupus nephritis
Common Signs & Symptoms of Uremia in Lupus:
Altered mental status (confusion, lethargy)
Fatigue or weakness
Nausea and vomiting
Anorexia
Itchy skin (uremic pruritus)
Fluid retention (edema, particularly in the lower extremities)
Hypertension (due to fluid overload)
Pale skin (due to anemia, which is common in SLE)
Diagnostic Approach SLE Lupus
Elevated serum creatinine and blood urea nitrogen (BUN)
levels.Urinalysis showing proteinuria.24-hour urine protein
collection or protein-to-creatinine ratio.Creatinine clearance test
to evaluate kidney function.
,The nurse caring for a client with systemic lupus erythematosus
(SLE) would include which information in teaching about
triggers that can result in an exacerbation of the disease?
Ultraviolet (UV) light exposure.
Patient has excessive thirst, hunger and polyuria. Which lab
value needs to be reported? SATA - HGA1 of 7.1 and another
choice (cant remember but you will be able to see which value is
abnormal)
High blood glucose(e.g., >250 mg/dL or even higher)
Electrolyte imbalances(ex potassium)-dehydration or
acidosis.HgbA1c of 7.1%
A 30-year-old male with a family history of hypertrophic
cardiomyopathy (HCM) presents with symptoms of chest pain,
shortness of breath, and dizziness. An echocardiogram reveals
asymmetric septal hypertrophy. Which of the following
diagnostic findings or treatments requires immediate attention?
(Select all that apply.)
Severe left ventricular outflow tract (LVOT) obstruction.Cardiac
arrhythmia (e.g., ventricular tachycardia)
The nurse is providing teaching to a client with Type 2 diabetes
mellitus and peripheral neuropathy. Which information should
the nurse provide?
Family members can help with regular foot exams.
Four days following and abdominal aortic aneurysm repair, the
client is exhibiting edema of both lower extremities, and pedal
, pulses are not palpable.Which action should the nurse
implement first?
Assess pulses with a vascular Doppler.
When instructing a client on self-injecting insulin into the
abdomen, what guidance should the nurse provide during the
return demonstration?
Pinch a fold of skin to prevent injecting into the muscle.
The nurse is teaching a client of American Indian heritage how
to self-administer insulin. As the nurse describes the necessary
steps in the injection process, the client continuously avoids eye
contact and occasionally turns away from the nurse. Which
action is most appropriate for the nurse to take in this situation?
Rationale:direct eye contact can be seen as disrespectful or
confrontational, especially in formal settings. The client's
avoidance of eye contact likely reflects cultural norms, not
disinterest. Providing written instructions and a private space to
learn respects these cultural preferences while ensuring the
client receives the needed information.
Provide written instructions and a private place for the client to
learn independently.
The nurse is caring for a client in the post anesthesia care unit
(PACU) who underwent a thoracotomy two hours ago. The
nurse observes vital signs of a heart rate of 140 beats/minute, a
respiratory rate of 26 breaths/minute, and a blood pressure of
140/90 mm Hg. Which intervention is most important for the
nurse to implement?
Solutions
A client with draining skin lesions of the lover extremity is
admitted with possible Methicillin-Resistant Staphylococcus
Aureus (MRSA). Which nursing interventions should the nurse
include in the plan of care? (Select all that apply.)
Monitor the client's white blood cell count.Send wound drainage
for culture and sensitivity.Institute contact precautions for staff
and visitors.
A client with multiple sclerosis has urinary retention related to
sensorimotor details. Which action should the nurse include in
the client's plan of care?
Teach the client techniques for performing intermittent
catheterization.
An obese client with emphysema who smokes at least a pack of
cigarettes daily is admitted after experiencing a sudden increase
in dyspnea and activity intolerance. Oxygen therapy is initiated
and its determined that the client will be discharged with
oxygen. Which information is most important for the nurse to
emphasize in the discharge teaching plan?
Guidelines for oxygen use.
The nurse is caring for a client who reports a sudden, severe
headache, and facial numbness. The nurse asks the client to
smile and observes an uneven smile with facial droop the right
side and a hand grasp strength that is weaker on the right than
,the left. The client denies a recent history of headache or
trauma.Which intervention should the nurse should perform in
the immediate management of the client?
Start two large-bore IV catheters and review inclusion criteria
for IV fibrinolytic therapy.
A patient with Systemic Lupus Erythematosus (SLE) presents
with nausea, vomiting, confusion, and a history of edema.
Which of the following is the most likely cause of these
symptoms?
Uremia due to lupus nephritis
Common Signs & Symptoms of Uremia in Lupus:
Altered mental status (confusion, lethargy)
Fatigue or weakness
Nausea and vomiting
Anorexia
Itchy skin (uremic pruritus)
Fluid retention (edema, particularly in the lower extremities)
Hypertension (due to fluid overload)
Pale skin (due to anemia, which is common in SLE)
Diagnostic Approach SLE Lupus
Elevated serum creatinine and blood urea nitrogen (BUN)
levels.Urinalysis showing proteinuria.24-hour urine protein
collection or protein-to-creatinine ratio.Creatinine clearance test
to evaluate kidney function.
,The nurse caring for a client with systemic lupus erythematosus
(SLE) would include which information in teaching about
triggers that can result in an exacerbation of the disease?
Ultraviolet (UV) light exposure.
Patient has excessive thirst, hunger and polyuria. Which lab
value needs to be reported? SATA - HGA1 of 7.1 and another
choice (cant remember but you will be able to see which value is
abnormal)
High blood glucose(e.g., >250 mg/dL or even higher)
Electrolyte imbalances(ex potassium)-dehydration or
acidosis.HgbA1c of 7.1%
A 30-year-old male with a family history of hypertrophic
cardiomyopathy (HCM) presents with symptoms of chest pain,
shortness of breath, and dizziness. An echocardiogram reveals
asymmetric septal hypertrophy. Which of the following
diagnostic findings or treatments requires immediate attention?
(Select all that apply.)
Severe left ventricular outflow tract (LVOT) obstruction.Cardiac
arrhythmia (e.g., ventricular tachycardia)
The nurse is providing teaching to a client with Type 2 diabetes
mellitus and peripheral neuropathy. Which information should
the nurse provide?
Family members can help with regular foot exams.
Four days following and abdominal aortic aneurysm repair, the
client is exhibiting edema of both lower extremities, and pedal
, pulses are not palpable.Which action should the nurse
implement first?
Assess pulses with a vascular Doppler.
When instructing a client on self-injecting insulin into the
abdomen, what guidance should the nurse provide during the
return demonstration?
Pinch a fold of skin to prevent injecting into the muscle.
The nurse is teaching a client of American Indian heritage how
to self-administer insulin. As the nurse describes the necessary
steps in the injection process, the client continuously avoids eye
contact and occasionally turns away from the nurse. Which
action is most appropriate for the nurse to take in this situation?
Rationale:direct eye contact can be seen as disrespectful or
confrontational, especially in formal settings. The client's
avoidance of eye contact likely reflects cultural norms, not
disinterest. Providing written instructions and a private space to
learn respects these cultural preferences while ensuring the
client receives the needed information.
Provide written instructions and a private place for the client to
learn independently.
The nurse is caring for a client in the post anesthesia care unit
(PACU) who underwent a thoracotomy two hours ago. The
nurse observes vital signs of a heart rate of 140 beats/minute, a
respiratory rate of 26 breaths/minute, and a blood pressure of
140/90 mm Hg. Which intervention is most important for the
nurse to implement?
