WGU D454 Adult Health III Practice
Exam QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025
1. A nurse is caring for a client with severe sepsis. Which finding indicates
the development of septic shock?
• A. Hypoglycemia
• B. Bradycardia
• C. Hypotension unresponsive to fluid resuscitation
• D. Elevated platelet count
Hypotension that persists despite fluid replacement indicates
progression from sepsis to septic shock due to vasodilation and
capillary leakage.
2. A patient with a spinal cord injury at T6 suddenly develops a severe
headache, flushing, and hypertension. What should the nurse do first?
,• A. Call the provider
• B. Administer antihypertensive
• C. Elevate the head of the bed
• D. Check the respiratory rate
Autonomic dysreflexia is a medical emergency. Elevating the HOB
reduces blood pressure and prevents stroke.
3. A nurse is assessing a client with heart failure who reports a 5-pound
weight gain in 2 days. What is the priority action?
• A. Increase diuretics
• B. Notify the provider
• C. Assess for edema and lung sounds
• D. Restrict protein intake
A sudden weight gain may indicate fluid overload. Assessment helps
determine the extent and urgency.
4. Which lab result requires immediate intervention for a patient
receiving IV heparin?
• A. Hemoglobin 11.5 g/dL
• B. aPTT 120 seconds
• C. Platelets 200,000
,• D. INR 1.2
An aPTT >100 seconds increases the risk of bleeding; therapeutic
range is 46–70 seconds.
5. A client receiving TPN via central line develops sudden SOB and chest
pain. What should the nurse do first?
• A. Stop the TPN
• B. Clamp the catheter and place client in left Trendelenburg
• C. Call the provider
• D. Administer oxygen
Suspected air embolism requires clamping the line and left
Trendelenburg to trap the air in the right atrium.
6. Which condition is most concerning in a patient with cirrhosis?
• A. Low albumin
• B. Jaundice
• C. Confusion and asterixis
• D. Weight loss
Confusion and asterixis indicate hepatic encephalopathy, a life-
threatening complication.
7. A nurse reviews telemetry and sees a patient in ventricular
tachycardia without a pulse. What is the priority?
• A. Begin CPR and prepare for defibrillation
, • B. Administer amiodarone
• C. Check blood glucose
• D. Notify the provider
Pulseless VT is treated as a cardiac arrest – immediate CPR and
defibrillation are required.
8. A patient with a new ileostomy is at greatest risk for which
complication?
• A. Constipation
• B. Fluid and electrolyte imbalance
• C. Fistula formation
• D. Obstruction
Ileostomies drain large amounts of fluid and electrolytes, increasing
the risk for imbalance.
9. What is the best way to confirm placement of a nasogastric tube?
• A. Auscultate air bolus
• B. Measure tube length
• C. Obtain a chest X-ray
• D. Check gastric pH
X-ray is the gold standard for verifying NG tube placement.
10. A patient with DKA has potassium 3.0 mEq/L. What is the nurse’s
priority?
Exam QUESTIONS AND CORRECT
ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2025
1. A nurse is caring for a client with severe sepsis. Which finding indicates
the development of septic shock?
• A. Hypoglycemia
• B. Bradycardia
• C. Hypotension unresponsive to fluid resuscitation
• D. Elevated platelet count
Hypotension that persists despite fluid replacement indicates
progression from sepsis to septic shock due to vasodilation and
capillary leakage.
2. A patient with a spinal cord injury at T6 suddenly develops a severe
headache, flushing, and hypertension. What should the nurse do first?
,• A. Call the provider
• B. Administer antihypertensive
• C. Elevate the head of the bed
• D. Check the respiratory rate
Autonomic dysreflexia is a medical emergency. Elevating the HOB
reduces blood pressure and prevents stroke.
3. A nurse is assessing a client with heart failure who reports a 5-pound
weight gain in 2 days. What is the priority action?
• A. Increase diuretics
• B. Notify the provider
• C. Assess for edema and lung sounds
• D. Restrict protein intake
A sudden weight gain may indicate fluid overload. Assessment helps
determine the extent and urgency.
4. Which lab result requires immediate intervention for a patient
receiving IV heparin?
• A. Hemoglobin 11.5 g/dL
• B. aPTT 120 seconds
• C. Platelets 200,000
,• D. INR 1.2
An aPTT >100 seconds increases the risk of bleeding; therapeutic
range is 46–70 seconds.
5. A client receiving TPN via central line develops sudden SOB and chest
pain. What should the nurse do first?
• A. Stop the TPN
• B. Clamp the catheter and place client in left Trendelenburg
• C. Call the provider
• D. Administer oxygen
Suspected air embolism requires clamping the line and left
Trendelenburg to trap the air in the right atrium.
6. Which condition is most concerning in a patient with cirrhosis?
• A. Low albumin
• B. Jaundice
• C. Confusion and asterixis
• D. Weight loss
Confusion and asterixis indicate hepatic encephalopathy, a life-
threatening complication.
7. A nurse reviews telemetry and sees a patient in ventricular
tachycardia without a pulse. What is the priority?
• A. Begin CPR and prepare for defibrillation
, • B. Administer amiodarone
• C. Check blood glucose
• D. Notify the provider
Pulseless VT is treated as a cardiac arrest – immediate CPR and
defibrillation are required.
8. A patient with a new ileostomy is at greatest risk for which
complication?
• A. Constipation
• B. Fluid and electrolyte imbalance
• C. Fistula formation
• D. Obstruction
Ileostomies drain large amounts of fluid and electrolytes, increasing
the risk for imbalance.
9. What is the best way to confirm placement of a nasogastric tube?
• A. Auscultate air bolus
• B. Measure tube length
• C. Obtain a chest X-ray
• D. Check gastric pH
X-ray is the gold standard for verifying NG tube placement.
10. A patient with DKA has potassium 3.0 mEq/L. What is the nurse’s
priority?
