WGU D439 NURS 1011 Foundations of Nursing –
Bachelor of Science in Nursing Prelicensure (Pre-
Nursing) Study Guide, Original Practice Questions &
Answers, Assessment Preparation, Comprehensive
Nursing Foundations Review, Professional Nursing
Concepts, Patient-Centered Care, Nursing Skills,
Safety, Clinical Practice, Communication &
Evidence-Based Nursing
Question 1: A patient with end-stage renal disease is scheduled for
hemodialysis. Which assessment finding should the nurse prioritize reporting
to the healthcare provider immediately?
A. Blood pressure of 150/90 mmHg
B. Heart rate of 88 beats per minute
C. Temperature of 99.2°F (37.3°C)
D. Potassium level of 6.8 mEq/L
CORRECT ANSWER: D. Potassium level of 6.8 mEq/L
Rationale: A potassium level of 6.8 mEq/L is critically elevated and places the patient at
high risk for life-threatening cardiac dysrhythmias. While hypertension, mild tachycardia,
and low-grade fever require monitoring and intervention, they do not present the
immediate life-threatening risk of severe hyperkalemia. The nurse must report this
critical lab value to the provider immediately so that urgent interventions, such as
emergent dialysis or potassium-lowering medications, can be initiated.
Question 2: A nurse is planning care for a patient with a suspected deep vein
thrombosis (DVT) in the left calf. Which intervention should be included in the
plan of care?
A. Apply heat to the left calf to promote circulation
B. Ambulate the patient frequently to prevent complications
C. Maintain strict bed rest with the affected leg elevated
D. Massage the left calf gently to reduce pain and swelling
CORRECT ANSWER: C. Maintain strict bed rest with the affected leg elevated
Rationale: For a patient with a suspected DVT, the standard of care includes bed rest
with the affected extremity elevated to promote venous return and reduce edema.
Applying heat, massaging the affected leg, or ambulating the patient can dislodge the
thrombus, leading to a pulmonary embolism, and are therefore contraindicated.
Question 3: Which of the following respiratory patterns is most characteristic
of metabolic acidosis, such as in diabetic ketoacidosis (DKA)?
A. Cheyne-Stokes respirations
B. Biot's respirations
,C. Kussmaul respirations
D. Apneustic breathing
CORRECT ANSWER: C. Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid, and labored breaths that are the body's
compensatory mechanism to blow off excess carbon dioxide in an attempt to lower
serum acidity in metabolic acidosis. Cheyne-Stokes respirations are associated with
brain injury and heart failure. Biot's respirations are seen in central nervous system
disorders. Apneustic breathing is associated with brainstem damage.
Question 4: A patient is receiving IV vancomycin. The nurse notes that the
patient has developed a flushing, erythematous rash on the face and upper
torso. What is the priority nursing action?
A. Stop the infusion and notify the healthcare provider
B. Slow the infusion rate and document the finding
C. Administer IV diphenhydramine as a one-time dose
D. Apply a cool compress to the affected skin areas
CORRECT ANSWER: A. Stop the infusion and notify the healthcare provider
Rationale: A flushing, erythematous rash on the face and upper torso is a classic sign of
"Red Man Syndrome," which is a hypersensitivity reaction to vancomycin caused by
rapid infusion. The priority action is to stop the infusion to prevent further deterioration
and then notify the provider. Slowing the infusion rate is a preventative measure before
an infusion begins, but it is not the appropriate initial action once the syndrome has
developed.
Question 5: A nurse is performing a cardiovascular assessment on a patient.
Which finding warrants further investigation?
A. S1 and S2 heart sounds audible
B. Capillary refill time of less than 2 seconds
C. A palpable thrill at the carotid artery
D. A blood pressure of 118/76 mmHg
CORRECT ANSWER: C. A palpable thrill at the carotid artery
Rationale: A palpable thrill, a palpable vibration, is considered an abnormal finding that
is often associated with arterial or vascular obstruction, turbulent blood flow, or an
aneurysm. S1 and S2 heart sounds, a capillary refill time under 2 seconds, and a blood
pressure of 118/76 mmHg are all normal cardiovascular assessment findings.
Question 6: A patient with chronic heart failure is prescribed digoxin. Which
laboratory value places the patient at the highest risk for digoxin toxicity?
A. Serum sodium of 135 mEq/L
B. Serum creatinine of 1.2 mg/dL
,C. Serum potassium of 3.2 mEq/L
D. Serum calcium of 10.2 mg/dL
CORRECT ANSWER: C. Serum potassium of 3.2 mEq/L
Rationale: Hypokalemia (potassium < 3.5 mEq/L) significantly increases the risk of
digoxin toxicity. Hypokalemia enhances the binding of digoxin to the Na-K-ATPase
pump in the cardiac muscle, increasing the drug's effects and risk of toxicity. Other
electrolyte imbalances may affect the patient, but hypokalemia is the most significant
risk factor for digoxin toxicity.
Question 7: A nurse is changing a colostomy bag and notes that the stoma
appears pale and dusky. What is the appropriate nursing action?
A. Apply a barrier cream around the stoma
B. Document the finding and apply a new bag
C. Notify the healthcare provider immediately
D. Gently massage the stoma to promote blood flow
CORRECT ANSWER: C. Notify the healthcare provider immediately
Rationale: A pale or dusky stoma indicates poor blood supply to the stoma, which can
be a sign of ischemia or necrosis. This is a medical emergency that requires immediate
attention from the healthcare provider to prevent the stoma tissue from dying. Massage
is contraindicated and could cause further tissue damage.
Question 8: Which of the following is the primary purpose of applying a
pneumatic compression device (PCD) to a postoperative patient?
A. To provide comfort by massaging the legs
B. To prevent deep vein thrombosis (DVT)
C. To assess for peripheral neuropathy
D. To treat venous stasis ulcers
CORRECT ANSWER: B. To prevent deep vein thrombosis (DVT)
Rationale: The primary purpose of a pneumatic compression device is to prevent deep
vein thrombosis (DVT). It accomplishes this by periodically inflating and deflating to
facilitate venous return from the lower extremities, which helps to prevent blood stasis
and the formation of thrombi. It is not primarily used for comfort, neuropathy
assessment, or treating active ulcers.
Question 9: A patient on a telemetry unit has a new order for a 12-lead EKG.
Which of the following is the correct placement for the V4 lead?
A. Fourth intercostal space at the right sternal border
B. Fourth intercostal space at the left sternal border
C. Fifth intercostal space at the midclavicular line
D. Fifth intercostal space at the anterior axillary line
CORRECT ANSWER: C. Fifth intercostal space at the midclavicular line
, Rationale: The V4 lead is placed in the fifth intercostal space at the midclavicular line.
V1 is at the fourth intercostal space, right sternal border; V2 is at the fourth intercostal
space, left sternal border; and V5 is at the anterior axillary line.
Question 10: A diabetic patient is experiencing diaphoresis, pallor, and
confusion. What is the priority nursing intervention?
A. Administer sliding scale insulin
B. Check the patient's blood glucose level
C. Give the patient a glass of orange juice
D. Reassure the patient and monitor closely
CORRECT ANSWER: B. Check the patient's blood glucose level
Rationale: Diaphoresis, pallor, and confusion are classic signs of hypoglycemia. The
priority action is to confirm the suspicion by checking the patient's blood glucose level.
While administering orange juice (or a fast-acting carbohydrate) is the correct treatment
for hypoglycemia, it is only done after verifying a low blood glucose reading to avoid
causing hyperglycemia.
Question 11: When assessing a patient's wound, which of the following
findings would indicate the wound is infected?
A. Serosanguineous drainage
B. Bright red granulation tissue
C. Foul-smelling purulent drainage
D. Moderate amount of serous drainage
CORRECT ANSWER: C. Foul-smelling purulent drainage
Rationale: Foul-smelling purulent drainage is a classic sign of a wound infection.
Serosanguineous, serous, and bright red granulation tissue are all normal findings during
the wound healing process and do not indicate infection on their own.
Question 12: A patient is prescribed warfarin for atrial fibrillation. What is the
primary laboratory test used to monitor the therapeutic effect of this
medication?
A. Complete blood count (CBC)
B. International normalized ratio (INR)
C. Partial thromboplastin time (PTT)
D. Platelet count
CORRECT ANSWER: B. International normalized ratio (INR)
Rationale: The therapeutic effect of warfarin is monitored using the International
Normalized Ratio (INR). Warfarin inhibits vitamin K-dependent clotting factors, and the
INR provides a standardized measure of its effect on the coagulation cascade. PTT is
used to monitor heparin therapy.
Bachelor of Science in Nursing Prelicensure (Pre-
Nursing) Study Guide, Original Practice Questions &
Answers, Assessment Preparation, Comprehensive
Nursing Foundations Review, Professional Nursing
Concepts, Patient-Centered Care, Nursing Skills,
Safety, Clinical Practice, Communication &
Evidence-Based Nursing
Question 1: A patient with end-stage renal disease is scheduled for
hemodialysis. Which assessment finding should the nurse prioritize reporting
to the healthcare provider immediately?
A. Blood pressure of 150/90 mmHg
B. Heart rate of 88 beats per minute
C. Temperature of 99.2°F (37.3°C)
D. Potassium level of 6.8 mEq/L
CORRECT ANSWER: D. Potassium level of 6.8 mEq/L
Rationale: A potassium level of 6.8 mEq/L is critically elevated and places the patient at
high risk for life-threatening cardiac dysrhythmias. While hypertension, mild tachycardia,
and low-grade fever require monitoring and intervention, they do not present the
immediate life-threatening risk of severe hyperkalemia. The nurse must report this
critical lab value to the provider immediately so that urgent interventions, such as
emergent dialysis or potassium-lowering medications, can be initiated.
Question 2: A nurse is planning care for a patient with a suspected deep vein
thrombosis (DVT) in the left calf. Which intervention should be included in the
plan of care?
A. Apply heat to the left calf to promote circulation
B. Ambulate the patient frequently to prevent complications
C. Maintain strict bed rest with the affected leg elevated
D. Massage the left calf gently to reduce pain and swelling
CORRECT ANSWER: C. Maintain strict bed rest with the affected leg elevated
Rationale: For a patient with a suspected DVT, the standard of care includes bed rest
with the affected extremity elevated to promote venous return and reduce edema.
Applying heat, massaging the affected leg, or ambulating the patient can dislodge the
thrombus, leading to a pulmonary embolism, and are therefore contraindicated.
Question 3: Which of the following respiratory patterns is most characteristic
of metabolic acidosis, such as in diabetic ketoacidosis (DKA)?
A. Cheyne-Stokes respirations
B. Biot's respirations
,C. Kussmaul respirations
D. Apneustic breathing
CORRECT ANSWER: C. Kussmaul respirations
Rationale: Kussmaul respirations are deep, rapid, and labored breaths that are the body's
compensatory mechanism to blow off excess carbon dioxide in an attempt to lower
serum acidity in metabolic acidosis. Cheyne-Stokes respirations are associated with
brain injury and heart failure. Biot's respirations are seen in central nervous system
disorders. Apneustic breathing is associated with brainstem damage.
Question 4: A patient is receiving IV vancomycin. The nurse notes that the
patient has developed a flushing, erythematous rash on the face and upper
torso. What is the priority nursing action?
A. Stop the infusion and notify the healthcare provider
B. Slow the infusion rate and document the finding
C. Administer IV diphenhydramine as a one-time dose
D. Apply a cool compress to the affected skin areas
CORRECT ANSWER: A. Stop the infusion and notify the healthcare provider
Rationale: A flushing, erythematous rash on the face and upper torso is a classic sign of
"Red Man Syndrome," which is a hypersensitivity reaction to vancomycin caused by
rapid infusion. The priority action is to stop the infusion to prevent further deterioration
and then notify the provider. Slowing the infusion rate is a preventative measure before
an infusion begins, but it is not the appropriate initial action once the syndrome has
developed.
Question 5: A nurse is performing a cardiovascular assessment on a patient.
Which finding warrants further investigation?
A. S1 and S2 heart sounds audible
B. Capillary refill time of less than 2 seconds
C. A palpable thrill at the carotid artery
D. A blood pressure of 118/76 mmHg
CORRECT ANSWER: C. A palpable thrill at the carotid artery
Rationale: A palpable thrill, a palpable vibration, is considered an abnormal finding that
is often associated with arterial or vascular obstruction, turbulent blood flow, or an
aneurysm. S1 and S2 heart sounds, a capillary refill time under 2 seconds, and a blood
pressure of 118/76 mmHg are all normal cardiovascular assessment findings.
Question 6: A patient with chronic heart failure is prescribed digoxin. Which
laboratory value places the patient at the highest risk for digoxin toxicity?
A. Serum sodium of 135 mEq/L
B. Serum creatinine of 1.2 mg/dL
,C. Serum potassium of 3.2 mEq/L
D. Serum calcium of 10.2 mg/dL
CORRECT ANSWER: C. Serum potassium of 3.2 mEq/L
Rationale: Hypokalemia (potassium < 3.5 mEq/L) significantly increases the risk of
digoxin toxicity. Hypokalemia enhances the binding of digoxin to the Na-K-ATPase
pump in the cardiac muscle, increasing the drug's effects and risk of toxicity. Other
electrolyte imbalances may affect the patient, but hypokalemia is the most significant
risk factor for digoxin toxicity.
Question 7: A nurse is changing a colostomy bag and notes that the stoma
appears pale and dusky. What is the appropriate nursing action?
A. Apply a barrier cream around the stoma
B. Document the finding and apply a new bag
C. Notify the healthcare provider immediately
D. Gently massage the stoma to promote blood flow
CORRECT ANSWER: C. Notify the healthcare provider immediately
Rationale: A pale or dusky stoma indicates poor blood supply to the stoma, which can
be a sign of ischemia or necrosis. This is a medical emergency that requires immediate
attention from the healthcare provider to prevent the stoma tissue from dying. Massage
is contraindicated and could cause further tissue damage.
Question 8: Which of the following is the primary purpose of applying a
pneumatic compression device (PCD) to a postoperative patient?
A. To provide comfort by massaging the legs
B. To prevent deep vein thrombosis (DVT)
C. To assess for peripheral neuropathy
D. To treat venous stasis ulcers
CORRECT ANSWER: B. To prevent deep vein thrombosis (DVT)
Rationale: The primary purpose of a pneumatic compression device is to prevent deep
vein thrombosis (DVT). It accomplishes this by periodically inflating and deflating to
facilitate venous return from the lower extremities, which helps to prevent blood stasis
and the formation of thrombi. It is not primarily used for comfort, neuropathy
assessment, or treating active ulcers.
Question 9: A patient on a telemetry unit has a new order for a 12-lead EKG.
Which of the following is the correct placement for the V4 lead?
A. Fourth intercostal space at the right sternal border
B. Fourth intercostal space at the left sternal border
C. Fifth intercostal space at the midclavicular line
D. Fifth intercostal space at the anterior axillary line
CORRECT ANSWER: C. Fifth intercostal space at the midclavicular line
, Rationale: The V4 lead is placed in the fifth intercostal space at the midclavicular line.
V1 is at the fourth intercostal space, right sternal border; V2 is at the fourth intercostal
space, left sternal border; and V5 is at the anterior axillary line.
Question 10: A diabetic patient is experiencing diaphoresis, pallor, and
confusion. What is the priority nursing intervention?
A. Administer sliding scale insulin
B. Check the patient's blood glucose level
C. Give the patient a glass of orange juice
D. Reassure the patient and monitor closely
CORRECT ANSWER: B. Check the patient's blood glucose level
Rationale: Diaphoresis, pallor, and confusion are classic signs of hypoglycemia. The
priority action is to confirm the suspicion by checking the patient's blood glucose level.
While administering orange juice (or a fast-acting carbohydrate) is the correct treatment
for hypoglycemia, it is only done after verifying a low blood glucose reading to avoid
causing hyperglycemia.
Question 11: When assessing a patient's wound, which of the following
findings would indicate the wound is infected?
A. Serosanguineous drainage
B. Bright red granulation tissue
C. Foul-smelling purulent drainage
D. Moderate amount of serous drainage
CORRECT ANSWER: C. Foul-smelling purulent drainage
Rationale: Foul-smelling purulent drainage is a classic sign of a wound infection.
Serosanguineous, serous, and bright red granulation tissue are all normal findings during
the wound healing process and do not indicate infection on their own.
Question 12: A patient is prescribed warfarin for atrial fibrillation. What is the
primary laboratory test used to monitor the therapeutic effect of this
medication?
A. Complete blood count (CBC)
B. International normalized ratio (INR)
C. Partial thromboplastin time (PTT)
D. Platelet count
CORRECT ANSWER: B. International normalized ratio (INR)
Rationale: The therapeutic effect of warfarin is monitored using the International
Normalized Ratio (INR). Warfarin inhibits vitamin K-dependent clotting factors, and the
INR provides a standardized measure of its effect on the coagulation cascade. PTT is
used to monitor heparin therapy.
