1|Page
WGU D115 OBJECTIVE ASSESSMENT
FINAL NEWEST ACTUAL EXAM| 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES |RATED
A + | NEW AND REVISED
1. A patient with a history of hypertension presents with a
headache and blurred vision. Which initial nursing action is
most appropriate?
A. Administer acetaminophen
B. Encourage rest in a dark room
C. Assess blood pressure and neurological status
D. Call family to provide reassurance
Rationale: Monitoring vital signs and neurological status is
the priority to assess for hypertensive crisis or other
complications.
2. A nurse is teaching a patient about a new prescription for
warfarin. Which statement by the patient indicates
understanding?
A. "I should stop taking vitamin K completely."
B. "I will take extra doses if I forget one."
C. "I should report any unusual bruising or bleeding to
my doctor."
D. "I can eat unlimited green leafy vegetables."
,2|Page
Rationale: Warfarin affects clotting; unusual bleeding is a
critical side effect to report. Vitamin K intake should be
consistent, not eliminated.
3. A patient with type 2 diabetes reports dizziness and
sweating. Which action should the nurse take first?
A. Administer insulin
B. Check the patient’s blood glucose level
C. Encourage deep breathing
D. Notify the physician immediately
Rationale: Symptoms suggest hypoglycemia; verifying blood
glucose is the first step before treatment.
4. A patient refuses a blood transfusion due to religious
beliefs. What is the nurse’s most appropriate response?
A. Persuade the patient to accept transfusion
B. Document the refusal and notify the provider
C. Administer blood anyway
D. Ignore the refusal
Rationale: Patient autonomy must be respected; refusal should
be documented and communicated.
5. A nurse is caring for a postoperative patient who has
sudden shortness of breath, chest pain, and tachycardia.
Which action is highest priority?
A. Obtain a full medical history
B. Encourage deep breathing exercises
C. Call rapid response and prepare for emergency
intervention
D. Administer pain medication
,3|Page
Rationale: These are signs of a potential pulmonary embolism,
which is life-threatening and requires immediate action.
6. A nurse is delegating tasks to a nursing assistant. Which
task is appropriate to delegate?
A. Assessing a patient’s new symptoms
B. Assisting a stable patient with bathing
C. Developing the care plan
D. Administering intravenous medications
Rationale: Basic care tasks can be delegated; assessment and
medication administration require professional nursing
judgment.
7. A patient with chronic kidney disease has hyperkalemia.
Which intervention should the nurse anticipate?
A. Encourage high-potassium diet
B. Administer kayexalate or other potassium-lowering
treatment as ordered
C. Restrict fluids only
D. Administer potassium supplements
Rationale: Hyperkalemia is dangerous; medications may be
ordered to lower potassium levels safely.
8. A nurse observes a coworker documenting care that was
not performed. Which is the correct action?
A. Ignore it
B. Confront the coworker aggressively
C. Report the incident according to facility policy
D. Correct the chart without notification
, 4|Page
Rationale: Falsifying documentation is unethical and illegal;
reporting according to policy ensures patient safety and
professional standards.
9. A patient with COPD is receiving oxygen via nasal
cannula. The patient becomes confused and drowsy. What
should the nurse do first?
A. Increase oxygen flow
B. Assess oxygen saturation and respiratory status
C. Call the physician
D. Encourage coughing
Rationale: Confusion and drowsiness may indicate CO2
retention; assessing the patient guides safe intervention.
10. A nurse is preparing to administer a new medication.
Which is the most important step to prevent medication
errors?
A. Shake the medication well
B. Perform the “five rights” of medication
administration
C. Check the patient’s room number
D. Ask the patient’s family for permission
Rationale: The “five rights” (right patient, medication, dose,
route, time) are critical for safe administration.
11. A patient with a nasogastric tube has abdominal
distention and vomiting. What is the nurse’s priority
action?
A. Record intake and output
B. Administer antiemetic
WGU D115 OBJECTIVE ASSESSMENT
FINAL NEWEST ACTUAL EXAM| 200
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES |RATED
A + | NEW AND REVISED
1. A patient with a history of hypertension presents with a
headache and blurred vision. Which initial nursing action is
most appropriate?
A. Administer acetaminophen
B. Encourage rest in a dark room
C. Assess blood pressure and neurological status
D. Call family to provide reassurance
Rationale: Monitoring vital signs and neurological status is
the priority to assess for hypertensive crisis or other
complications.
2. A nurse is teaching a patient about a new prescription for
warfarin. Which statement by the patient indicates
understanding?
A. "I should stop taking vitamin K completely."
B. "I will take extra doses if I forget one."
C. "I should report any unusual bruising or bleeding to
my doctor."
D. "I can eat unlimited green leafy vegetables."
,2|Page
Rationale: Warfarin affects clotting; unusual bleeding is a
critical side effect to report. Vitamin K intake should be
consistent, not eliminated.
3. A patient with type 2 diabetes reports dizziness and
sweating. Which action should the nurse take first?
A. Administer insulin
B. Check the patient’s blood glucose level
C. Encourage deep breathing
D. Notify the physician immediately
Rationale: Symptoms suggest hypoglycemia; verifying blood
glucose is the first step before treatment.
4. A patient refuses a blood transfusion due to religious
beliefs. What is the nurse’s most appropriate response?
A. Persuade the patient to accept transfusion
B. Document the refusal and notify the provider
C. Administer blood anyway
D. Ignore the refusal
Rationale: Patient autonomy must be respected; refusal should
be documented and communicated.
5. A nurse is caring for a postoperative patient who has
sudden shortness of breath, chest pain, and tachycardia.
Which action is highest priority?
A. Obtain a full medical history
B. Encourage deep breathing exercises
C. Call rapid response and prepare for emergency
intervention
D. Administer pain medication
,3|Page
Rationale: These are signs of a potential pulmonary embolism,
which is life-threatening and requires immediate action.
6. A nurse is delegating tasks to a nursing assistant. Which
task is appropriate to delegate?
A. Assessing a patient’s new symptoms
B. Assisting a stable patient with bathing
C. Developing the care plan
D. Administering intravenous medications
Rationale: Basic care tasks can be delegated; assessment and
medication administration require professional nursing
judgment.
7. A patient with chronic kidney disease has hyperkalemia.
Which intervention should the nurse anticipate?
A. Encourage high-potassium diet
B. Administer kayexalate or other potassium-lowering
treatment as ordered
C. Restrict fluids only
D. Administer potassium supplements
Rationale: Hyperkalemia is dangerous; medications may be
ordered to lower potassium levels safely.
8. A nurse observes a coworker documenting care that was
not performed. Which is the correct action?
A. Ignore it
B. Confront the coworker aggressively
C. Report the incident according to facility policy
D. Correct the chart without notification
, 4|Page
Rationale: Falsifying documentation is unethical and illegal;
reporting according to policy ensures patient safety and
professional standards.
9. A patient with COPD is receiving oxygen via nasal
cannula. The patient becomes confused and drowsy. What
should the nurse do first?
A. Increase oxygen flow
B. Assess oxygen saturation and respiratory status
C. Call the physician
D. Encourage coughing
Rationale: Confusion and drowsiness may indicate CO2
retention; assessing the patient guides safe intervention.
10. A nurse is preparing to administer a new medication.
Which is the most important step to prevent medication
errors?
A. Shake the medication well
B. Perform the “five rights” of medication
administration
C. Check the patient’s room number
D. Ask the patient’s family for permission
Rationale: The “five rights” (right patient, medication, dose,
route, time) are critical for safe administration.
11. A patient with a nasogastric tube has abdominal
distention and vomiting. What is the nurse’s priority
action?
A. Record intake and output
B. Administer antiemetic
