WGU D439 oa actual questions With 100% accurate solutions 2026

When planning the care schedule for a bedfast client, what is the most important assessment finding to consider?

Braden Risk Assessment Score of 10.

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?

Evaluate both clients' pain using the standardized pain scale.

The client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take?

Encourage the spouse to share their feelings.

When assessing a client with a serum potassium level of 2.5 mEq, which assessment is most important for the nurse to perform?

Determine apical heart rate and rhythm.

The nurse assesses a client who has a nasal cannula delivering oxygen to determine if there is any skin irritation from the cannula. Which areas should the nurse observe?

Top of the ears, around the nostrils, over the cheeks.

A client with fluid overload is admitted to the hospital for diuresis. Which assessment should the nurse use to evaluate fluid balance?

Weight

A client with primary angular glaucoma received a prescription to use an eyedrop. What should the nurse plan to include in the client's teaching?

Do not allow the dropper to touch the eye.

A male client has right-sided hemiplegia following a left cerebral vascular accident. The client is able to sit in a wheelchair. To assist the client in transferring from the bed to the wheelchair, which action should the nurse take?

Place the wheelchair on the left side.

A client with a sprained ankle is seen at the clinic and is given a prescription for crutches. The nurse notes a space of three-finger width between the top of the crutch and the axilla (underarm). What should the nurse do?

Concur with a physical therapist or care team about the crutch size.

When inhaling oxygen per mask to a client who is short of breath, the nurse hears a loud hissing sound after connecting the flow meter to the wall outlet. What should the nurse do next?

Release and restart the meter from the wall outlet.

A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take?

Place the wheelchair on the client's left side.

To assess the quality of an adult client's pain, what approach should the nurse use?

Ask the client to describe the pain.

A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should nurse implement?

Instruct the client to flex both of his feet several times a day.

The nurse is using guided imagery with a client who is experiencing chronic pain. The nurse should direct the client's attention on which focus?

Positive external places.

The nurse is caring for a client one week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

A well approximated Incision site.

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Bend the arm by flexing the ulnar to the humerus

The nurse is teaching the client to self administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse Include?

Inject In abdominal area at least 2 in (5.1 cm) from the umbilicus.

An unlicensed assistive personnel (UAP) is assigned to feed a client who has received a prescription to institute droplet precautions for a bacterial meningitis infection. The UAP requests a change in assignment, reporting having not yet been fitted for a particulate filter mask. Which action should the nurse take?

Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client.

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

"I can only give medical Information to your child because they are legally an adult."

A nurse stops at a motor vehicle collision to provide help for a victim who is trapped in an overturned running vehicle. The nurse turns off the engine key, and asks the client to wiggle the fingers because the client's head is impinged on the roof and the neck is bent to the left shoulder. After Emergency Medical Services (EMS) arrive, the nurse reports that the victim is conscious, but is not able to talk, and then the nurse leaves the scene. Which legal action can be taken in this situation?

Good Samaritan immunity.

A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Assist to a bedside commode 30 minutes after meals.

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which Intervention is most important for the nurse to implement before leaving the client alone?

Apply the client's positive airway pressure device.

Question about a family member wanting to translate for a non-English speaking patient

tell them you have to get a translator through the hospital

Stages of wound healing

1. Inflammatory (initial)

-immediate phase, lasts about 3 days

-increased blood supply and phagocytosis (delivers oxygen, wbcs, and nutrient to the wound to support healing)

-control bleeding for clot formation

2. Proliferative (granulation) (new blood vessels)

-second phase

-fibroblasts synthesize collagen

-formation of granulation tissue

3. Maturation and Remodeling

-continued granulation and strengthening of tissue

-scar formation

questions on how to lift a patient or bend

with knees! Do not bend at waist

A client was involved in a multicar collision six days ago and sustained a liver laceration, right rib fracture, and right femur fracture. The liver laceration was repaired. What are the recommended exercises and parameters to monitor?

Most Likely Condition

✅ Risk for venous thromboembolism

Recommended Nursing Actions

✅ Encourage ankle pumps and quadriceps sets ✅ Encourage isometric exercises of the unaffected extremities

Parameters to Monitor

✅ Calf pain and swelling ✅ Heart rate and activity tolerance

a client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

Call the pharmacy to see which medications should be taken.

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is No longer palpable at 90 mm Hg. Which action should the nurse take?

Inflate blood pressure cuff to 120 mm Hg.

The nurse is administering an intradermal injection to a client. Which action should the nurse take?

Ensure bevel of the needle is pointing up.

The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?

risk for impaired skin integrity

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male patient?

advance the catheter before inflating the baloon

the nurse pulled a bottle of potassium from the automated medication administration system. They went to the medication room to pull up the medication, and immedietly went to the clients room to administer the dose. The nurse did not realize they needed to calculate and pull the appropriate dose from the bottle and gave the entire volume for a total of 40 mEq. Which medication error prevention technique would have helped to avoid this error?

A. double check the dosage of high risk medications with another nurse

C. question unusually large or small doses

F. Do not allow other activity to interrupt medication administration

patient had 8 oz of chicken broth, 12 oz of coffee 450 ml of water then vomitied 6 oz. how many ml did the patient input?

870 mL net fluid balance

(this one's not the exact same question but there's one similar so know I&O math)

The healthcare provider prescribes cefixime oral suspension 200 mg PO twice a day for an older adult who has difficulty swallowing tablets. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

20 mL

A client receives a prescription for dextromethorphan 30 mg every 6 to 8 hours PO as needed for cough. The bottle is labeled "Dextromethorphan for Oral Suspension, USP 30 mg per 15 mL." How many tablespoons should the nurse instruct the client to take with each dose? (Enter numerical value only.)

1 tbsp

The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, "Streptomycin 1 gram/2.5 mL." How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

0.5 mL