WGU D439 FOUNDATIONS. EXAM
QUESTIONS AND ANSWERS | 2026
UPDATE | 100% CORRECT.
What can cause high blood pressure readings? - ANS Anxiety, wrong cuff size, talking, legs
crossed, arm not being level with heart, pain, dehydration, fever/infection, hyponatremia,
weight, alcohol/smoking, opioids, hypovolemia, hyper/hypokalemia, hyper/hypocalcemia
no radial pulse at 90 - ANS PUMP TO 120
how much to pump cuff - ANS at least 30 mm Hg above the point the radial pulse disappears
potassium levels involved - ANS heart: helps the heart squeeze
high potassium levels - ANS high apical pulse rate and rhythm
nursing charts by exception- lungs - ANS LUNG SOUNDS DIMINISHED IN LEFT LUNG not
normal
nasal cannula care: if patient has reddened areas around cheekbones - ANS PLACE PADDING
AROUND THE CANNULA TUBING
nasal cannula care: if patient's O2 readings improve with movement - ANS place the nasal
cannula in the nose securely
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 17
,nasal cannula care: O2 levels low - ANS VERIFY PLACEMENT OF PULSE OXIMETER
Oxygen chamber - ANS store in a cool area
Fall Prevention "H" - ANS Hourly rounds: check on patient HOURLY
Fall prevention "O" - ANS Organize belongings: use bed alarms
Fall Prevention "P" - ANS Position changes slow: ensure slow position changes and keep
everything needed within reach
Fall Prevention "E" - ANS Ensure lighting is sufficient: For elderly patients keep a well lit room
patient has sleep apnea and given sedative - ANS MAKE SURE AIRWAY PRESSURE DEVICE IS
ON
restraint types - ANS chemical & physical
restraint knot - ANS slip knots
restraint tying area - ANS BED FRAME ONLY
chemical restraints - ANS meds such as benzos
first thing to assess after restraint - ANS CAPILLARY REFILL
when to check capillary refill when restrained - ANS immediately and every 15 mins
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 17
, other checks when restrained - ANS skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
restraint documentation - ANS reasoning, mental status, care offered, time in restraints
restraint order time - ANS ONLY last 24 hours
urine specific gravity test use - ANS identify dehydration, kidney problems, conditions like
diabetes insipidus
urine specific gravity test & range - ANS concentration of particles in urine; 1.005- 1.030
high urine specific gravity test - ANS HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
low urine specific gravity test - ANS "overflow" kidney damage, kidney failure
pressure ulcers - ANS "1 red, 2 broken, 3 deep, 4 bone"
red intact skin, break with blister, deep tissue, bone visible
pressure ulcers stage 1 - ANS red intact skin
pressure ulcers stage 2 - ANS skin breaks & blisters; 2 layers affected (epidermis, dermis)
pressure ulcers stage 3 - ANS full thickness skin loss; 3 layers affected (epi, dermis, sub-q
tissue)
@COPYRIGHT ALL RIGHTS RESERVED PAGE 3 OF 17
QUESTIONS AND ANSWERS | 2026
UPDATE | 100% CORRECT.
What can cause high blood pressure readings? - ANS Anxiety, wrong cuff size, talking, legs
crossed, arm not being level with heart, pain, dehydration, fever/infection, hyponatremia,
weight, alcohol/smoking, opioids, hypovolemia, hyper/hypokalemia, hyper/hypocalcemia
no radial pulse at 90 - ANS PUMP TO 120
how much to pump cuff - ANS at least 30 mm Hg above the point the radial pulse disappears
potassium levels involved - ANS heart: helps the heart squeeze
high potassium levels - ANS high apical pulse rate and rhythm
nursing charts by exception- lungs - ANS LUNG SOUNDS DIMINISHED IN LEFT LUNG not
normal
nasal cannula care: if patient has reddened areas around cheekbones - ANS PLACE PADDING
AROUND THE CANNULA TUBING
nasal cannula care: if patient's O2 readings improve with movement - ANS place the nasal
cannula in the nose securely
@COPYRIGHT ALL RIGHTS RESERVED PAGE 1 OF 17
,nasal cannula care: O2 levels low - ANS VERIFY PLACEMENT OF PULSE OXIMETER
Oxygen chamber - ANS store in a cool area
Fall Prevention "H" - ANS Hourly rounds: check on patient HOURLY
Fall prevention "O" - ANS Organize belongings: use bed alarms
Fall Prevention "P" - ANS Position changes slow: ensure slow position changes and keep
everything needed within reach
Fall Prevention "E" - ANS Ensure lighting is sufficient: For elderly patients keep a well lit room
patient has sleep apnea and given sedative - ANS MAKE SURE AIRWAY PRESSURE DEVICE IS
ON
restraint types - ANS chemical & physical
restraint knot - ANS slip knots
restraint tying area - ANS BED FRAME ONLY
chemical restraints - ANS meds such as benzos
first thing to assess after restraint - ANS CAPILLARY REFILL
when to check capillary refill when restrained - ANS immediately and every 15 mins
@COPYRIGHT ALL RIGHTS RESERVED PAGE 2 OF 17
, other checks when restrained - ANS skin integrity, vital signs, ROM every 2 hours; offer
bathroom every 2 hours
restraint documentation - ANS reasoning, mental status, care offered, time in restraints
restraint order time - ANS ONLY last 24 hours
urine specific gravity test use - ANS identify dehydration, kidney problems, conditions like
diabetes insipidus
urine specific gravity test & range - ANS concentration of particles in urine; 1.005- 1.030
high urine specific gravity test - ANS HIGH = YOU'RE DRY/ DEHYDRATED =
VOMITING/DIARRHEA
low urine specific gravity test - ANS "overflow" kidney damage, kidney failure
pressure ulcers - ANS "1 red, 2 broken, 3 deep, 4 bone"
red intact skin, break with blister, deep tissue, bone visible
pressure ulcers stage 1 - ANS red intact skin
pressure ulcers stage 2 - ANS skin breaks & blisters; 2 layers affected (epidermis, dermis)
pressure ulcers stage 3 - ANS full thickness skin loss; 3 layers affected (epi, dermis, sub-q
tissue)
@COPYRIGHT ALL RIGHTS RESERVED PAGE 3 OF 17
