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, Nursing Concepts,
Patient Care, Safety, Clinical Skills, Professional
Nursing Practice, Communication & Nursing Process
Question 1: A client who has just been diagnosed with a chronic illness is
crying and states, "I can't do this. It's not fair." Which of the following nursing
responses is most therapeutic?
A. "I understand how you feel. It is a difficult diagnosis to accept."
B. "You should focus on the positive aspects of your life right now."
C. "This must be very difficult for you. I am here to listen if you want to talk."
D. "Have you considered talking to a therapist to help you cope?"
CORRECT ANSWER: C. This must be very difficult for you. I am here to listen if
you want to talk.
Rationale: This response uses a therapeutic communication technique that
acknowledges the client’s feelings and offers presence and support without judgment.
Option A is non-therapeutic as it assumes a shared understanding of the client's feelings.
Option B is dismissive of the client's current emotional state. Option D, while potentially
helpful later, is premature and does not address the client's immediate emotional needs.
Question 2: A nurse is preparing to administer a medication via the
subcutaneous route. Which of the following needle lengths is most appropriate
for an adult with average body mass?
A. 1 inch
B. 3/8 inch
C. 1 1/2 inch
D. 5/8 inch
CORRECT ANSWER: D. 5/8 inch
Rationale: A needle length of 5/8 inch is typically sufficient for a subcutaneous injection
in an adult with average body mass to ensure the medication is deposited into the
subcutaneous tissue. A 1-inch needle is often used for intramuscular injections. A 3/8
inch needle may be too short, and a 1 1/2 inch needle is too long, both risking
administration into the incorrect tissue layer.
Question 3: Which of the following clinical manifestations is a primary
indicator of a severe anaphylactic reaction to a medication?
A. Urticaria and pruritus
B. Wheezing and stridor
,C. Nausea and vomiting
D. Tachycardia and anxiety
CORRECT ANSWER: B. Wheezing and stridor
Rationale: Wheezing and stridor indicate significant bronchospasm and upper airway
edema, which are life-threatening signs of anaphylaxis. While urticaria, pruritus, nausea,
vomiting, tachycardia, and anxiety are all symptoms of an allergic reaction, airway
compromise (wheezing/stridor) is the primary indicator of a severe, life-threatening
anaphylactic reaction that requires immediate intervention.
Question 4: A nurse is assessing a client who is 24 hours post-operative from
an abdominal hysterectomy. Which of the following assessment findings would
be of most concern?
A. Client reports pain as 4 on a scale of 0 to 10.
B. Client has an oral temperature of 100.4°F (38°C).
C. Client's urinary output is 20 mL/hr.
D. Client has a hemoglobin level of 11.5 g/dL.
CORRECT ANSWER: C. Client's urinary output is 20 mL/hr.
Rationale: A urinary output of less than 30 mL/hr is a critical finding that may indicate
hypovolemia or acute kidney injury. This finding requires immediate notification of the
healthcare provider. A temperature of 100.4°F is a low-grade fever, which can be a
normal post-surgical response. A pain score of 4 is manageable. A hemoglobin of 11.5
g/dL is slightly low but expected post-operatively.
Question 5: A client with a history of heart failure is prescribed furosemide.
The nurse should monitor the client for which of the following electrolyte
imbalances?
A. Hyperkalemia
B. Hypermagnesemia
C. Hypokalemia
D. Hypercalcemia
CORRECT ANSWER: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that blocks the reabsorption of sodium,
chloride, and potassium in the ascending loop of Henle. This action leads to increased
potassium excretion, placing the client at risk for hypokalemia. The other options are
not typical adverse effects of furosemide.
Question 6: During a client's admission interview, the nurse notices that the
client speaks only in short sentences, avoids eye contact, and has a flat affect.
Which of the following is the nurse's priority action?
A. Document the client's behavior in the medical record.
B. Ask the client if they are feeling sad or depressed.
,C. Ensure the client is in a safe environment and assess for suicidal ideation.
D. Continue the admission interview to gather complete data.
CORRECT ANSWER: C. Ensure the client is in a safe environment and assess
for suicidal ideation.
Rationale: While the client's behavior suggests depression, the nurse's priority is to
assess for immediate safety risks, including suicidal ideation. This is a core responsibility
when dealing with clients who may be experiencing a mood disorder. Safety is
paramount, and this assessment must be performed before proceeding with other
aspects of the interview.
Question 7: A nurse is caring for a client receiving a continuous enteral feeding
through a nasogastric tube. Which of the following actions is most appropriate
to prevent aspiration?
A. Flush the tube with 30 mL of water every 2 hours.
B. Keep the head of the bed elevated to 30 degrees.
C. Check gastric residual volume every 4 hours.
D. Administer the feeding via a pump.
CORRECT ANSWER: B. Keep the head of the bed elevated to 30 degrees.
Rationale: Keeping the head of the bed elevated to at least 30 degrees (and ideally 45
degrees) is the most effective and evidence-based intervention to reduce the risk of
aspiration by preventing the backflow of gastric contents into the esophagus and
pharynx. Checking residual is important for monitoring tolerance but not the primary
prevention strategy.
Question 8: Which of the following findings in a newborn is considered a
normal variation and not a cause for immediate concern?
A. Nasal flaring
B. Grunting respirations
C. Intercostal retractions
D. Acrocyanosis
CORRECT ANSWER: D. Acrocyanosis
Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding
in newborns for the first 24-48 hours due to immature peripheral circulation. Nasal
flaring, grunting, and intercostal retractions are all signs of respiratory distress and
require immediate assessment and intervention.
Question 9: A nurse is performing a sterile wound dressing change. Which of
the following actions would indicate a break in sterile technique?
A. Opening the sterile packet away from the body.
B. Placing the sterile field within the nurse's line of sight.
, C. Pouring sterile solution onto the sterile field from a height of 6 inches.
D. Holding sterile objects above the waist.
CORRECT ANSWER: C. Pouring sterile solution onto the sterile field from a
height of 6 inches.
Rationale: A height of 6 inches is too close to the sterile field. Sterile solutions should be
poured from a height of 4 to 6 inches into a sterile receptacle, but not directly onto the
field, to avoid splashing and contaminating the field. The other options are appropriate
sterile techniques.
Question 10: A client is receiving a blood transfusion. Fifteen minutes after the
start of the transfusion, the client reports chills and low back pain. Which of
the following is the nurse's priority action?
A. Administer diphenhydramine as prescribed.
B. Stop the transfusion and disconnect the blood tubing.
C. Slow the infusion rate and assess vital signs.
D. Notify the healthcare provider.
CORRECT ANSWER: B. Stop the transfusion and disconnect the blood tubing.
Rationale: The client is displaying classic signs of an acute hemolytic transfusion
reaction (chills, low back pain). The immediate priority is to stop the infusion and
disconnect the blood tubing to prevent further administration of the incompatible blood.
Keeping the IV line open with saline is the next step, followed by notifying the provider.
Question 11: A nurse is reinforcing teaching with a client who has a new
prescription for an ACE inhibitor. Which of the following dietary instructions is
most important to include?
A. Avoid foods high in potassium.
B. Decrease intake of cruciferous vegetables.
C. Increase intake of calcium-rich foods.
D. Avoid foods containing tyramine.
CORRECT ANSWER: A. Avoid foods high in potassium.
Rationale: ACE inhibitors can cause hyperkalemia by reducing aldosterone secretion.
Clients should be taught to avoid or limit foods high in potassium (e.g., bananas,
oranges, potatoes). The other dietary restrictions are not directly associated with ACE
inhibitor therapy.
Question 12: A client experiencing heart failure is prescribed a loop diuretic
and an ACE inhibitor. The client's serum potassium level is 3.2 mEq/L. Which
of the following findings should the nurse report to the provider?
A. Client reports muscle twitching.
B. Client's blood pressure is 110/70 mmHg.
Bachelor of Science in Nursing Prelicensure (Pre-
Nursing) Study Guide, Original Practice Questions &
Answers, Assessment Preparation, Comprehensive
Nursing Foundations Review, Nursing Concepts,
Patient Care, Safety, Clinical Skills, Professional
Nursing Practice, Communication & Nursing Process
Question 1: A client who has just been diagnosed with a chronic illness is
crying and states, "I can't do this. It's not fair." Which of the following nursing
responses is most therapeutic?
A. "I understand how you feel. It is a difficult diagnosis to accept."
B. "You should focus on the positive aspects of your life right now."
C. "This must be very difficult for you. I am here to listen if you want to talk."
D. "Have you considered talking to a therapist to help you cope?"
CORRECT ANSWER: C. This must be very difficult for you. I am here to listen if
you want to talk.
Rationale: This response uses a therapeutic communication technique that
acknowledges the client’s feelings and offers presence and support without judgment.
Option A is non-therapeutic as it assumes a shared understanding of the client's feelings.
Option B is dismissive of the client's current emotional state. Option D, while potentially
helpful later, is premature and does not address the client's immediate emotional needs.
Question 2: A nurse is preparing to administer a medication via the
subcutaneous route. Which of the following needle lengths is most appropriate
for an adult with average body mass?
A. 1 inch
B. 3/8 inch
C. 1 1/2 inch
D. 5/8 inch
CORRECT ANSWER: D. 5/8 inch
Rationale: A needle length of 5/8 inch is typically sufficient for a subcutaneous injection
in an adult with average body mass to ensure the medication is deposited into the
subcutaneous tissue. A 1-inch needle is often used for intramuscular injections. A 3/8
inch needle may be too short, and a 1 1/2 inch needle is too long, both risking
administration into the incorrect tissue layer.
Question 3: Which of the following clinical manifestations is a primary
indicator of a severe anaphylactic reaction to a medication?
A. Urticaria and pruritus
B. Wheezing and stridor
,C. Nausea and vomiting
D. Tachycardia and anxiety
CORRECT ANSWER: B. Wheezing and stridor
Rationale: Wheezing and stridor indicate significant bronchospasm and upper airway
edema, which are life-threatening signs of anaphylaxis. While urticaria, pruritus, nausea,
vomiting, tachycardia, and anxiety are all symptoms of an allergic reaction, airway
compromise (wheezing/stridor) is the primary indicator of a severe, life-threatening
anaphylactic reaction that requires immediate intervention.
Question 4: A nurse is assessing a client who is 24 hours post-operative from
an abdominal hysterectomy. Which of the following assessment findings would
be of most concern?
A. Client reports pain as 4 on a scale of 0 to 10.
B. Client has an oral temperature of 100.4°F (38°C).
C. Client's urinary output is 20 mL/hr.
D. Client has a hemoglobin level of 11.5 g/dL.
CORRECT ANSWER: C. Client's urinary output is 20 mL/hr.
Rationale: A urinary output of less than 30 mL/hr is a critical finding that may indicate
hypovolemia or acute kidney injury. This finding requires immediate notification of the
healthcare provider. A temperature of 100.4°F is a low-grade fever, which can be a
normal post-surgical response. A pain score of 4 is manageable. A hemoglobin of 11.5
g/dL is slightly low but expected post-operatively.
Question 5: A client with a history of heart failure is prescribed furosemide.
The nurse should monitor the client for which of the following electrolyte
imbalances?
A. Hyperkalemia
B. Hypermagnesemia
C. Hypokalemia
D. Hypercalcemia
CORRECT ANSWER: C. Hypokalemia
Rationale: Furosemide is a loop diuretic that blocks the reabsorption of sodium,
chloride, and potassium in the ascending loop of Henle. This action leads to increased
potassium excretion, placing the client at risk for hypokalemia. The other options are
not typical adverse effects of furosemide.
Question 6: During a client's admission interview, the nurse notices that the
client speaks only in short sentences, avoids eye contact, and has a flat affect.
Which of the following is the nurse's priority action?
A. Document the client's behavior in the medical record.
B. Ask the client if they are feeling sad or depressed.
,C. Ensure the client is in a safe environment and assess for suicidal ideation.
D. Continue the admission interview to gather complete data.
CORRECT ANSWER: C. Ensure the client is in a safe environment and assess
for suicidal ideation.
Rationale: While the client's behavior suggests depression, the nurse's priority is to
assess for immediate safety risks, including suicidal ideation. This is a core responsibility
when dealing with clients who may be experiencing a mood disorder. Safety is
paramount, and this assessment must be performed before proceeding with other
aspects of the interview.
Question 7: A nurse is caring for a client receiving a continuous enteral feeding
through a nasogastric tube. Which of the following actions is most appropriate
to prevent aspiration?
A. Flush the tube with 30 mL of water every 2 hours.
B. Keep the head of the bed elevated to 30 degrees.
C. Check gastric residual volume every 4 hours.
D. Administer the feeding via a pump.
CORRECT ANSWER: B. Keep the head of the bed elevated to 30 degrees.
Rationale: Keeping the head of the bed elevated to at least 30 degrees (and ideally 45
degrees) is the most effective and evidence-based intervention to reduce the risk of
aspiration by preventing the backflow of gastric contents into the esophagus and
pharynx. Checking residual is important for monitoring tolerance but not the primary
prevention strategy.
Question 8: Which of the following findings in a newborn is considered a
normal variation and not a cause for immediate concern?
A. Nasal flaring
B. Grunting respirations
C. Intercostal retractions
D. Acrocyanosis
CORRECT ANSWER: D. Acrocyanosis
Rationale: Acrocyanosis, a bluish discoloration of the hands and feet, is a normal finding
in newborns for the first 24-48 hours due to immature peripheral circulation. Nasal
flaring, grunting, and intercostal retractions are all signs of respiratory distress and
require immediate assessment and intervention.
Question 9: A nurse is performing a sterile wound dressing change. Which of
the following actions would indicate a break in sterile technique?
A. Opening the sterile packet away from the body.
B. Placing the sterile field within the nurse's line of sight.
, C. Pouring sterile solution onto the sterile field from a height of 6 inches.
D. Holding sterile objects above the waist.
CORRECT ANSWER: C. Pouring sterile solution onto the sterile field from a
height of 6 inches.
Rationale: A height of 6 inches is too close to the sterile field. Sterile solutions should be
poured from a height of 4 to 6 inches into a sterile receptacle, but not directly onto the
field, to avoid splashing and contaminating the field. The other options are appropriate
sterile techniques.
Question 10: A client is receiving a blood transfusion. Fifteen minutes after the
start of the transfusion, the client reports chills and low back pain. Which of
the following is the nurse's priority action?
A. Administer diphenhydramine as prescribed.
B. Stop the transfusion and disconnect the blood tubing.
C. Slow the infusion rate and assess vital signs.
D. Notify the healthcare provider.
CORRECT ANSWER: B. Stop the transfusion and disconnect the blood tubing.
Rationale: The client is displaying classic signs of an acute hemolytic transfusion
reaction (chills, low back pain). The immediate priority is to stop the infusion and
disconnect the blood tubing to prevent further administration of the incompatible blood.
Keeping the IV line open with saline is the next step, followed by notifying the provider.
Question 11: A nurse is reinforcing teaching with a client who has a new
prescription for an ACE inhibitor. Which of the following dietary instructions is
most important to include?
A. Avoid foods high in potassium.
B. Decrease intake of cruciferous vegetables.
C. Increase intake of calcium-rich foods.
D. Avoid foods containing tyramine.
CORRECT ANSWER: A. Avoid foods high in potassium.
Rationale: ACE inhibitors can cause hyperkalemia by reducing aldosterone secretion.
Clients should be taught to avoid or limit foods high in potassium (e.g., bananas,
oranges, potatoes). The other dietary restrictions are not directly associated with ACE
inhibitor therapy.
Question 12: A client experiencing heart failure is prescribed a loop diuretic
and an ACE inhibitor. The client's serum potassium level is 3.2 mEq/L. Which
of the following findings should the nurse report to the provider?
A. Client reports muscle twitching.
B. Client's blood pressure is 110/70 mmHg.
