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, Patient Care, Nursing
Process, Safety, Communication, Professional
Nursing Concepts & Clinical Fundamentals
Question 1: A client who recently immigrated from a country with a high
prevalence of tuberculosis (TB) is scheduled for a Mantoux tuberculin skin test
(TST). Which nursing action is most critical prior to administering the test?
A. Assess the client’s arm for any rashes or lesions.
B. Ensure the client has not received the BCG vaccine.
C. Ask the client if they have a history of a positive TB test.
D. Verify the client’s ability to return for the reading in 48-72 hours.
CORRECT ANSWER: D. Verify the client’s ability to return for the reading in
48-72 hours.
Rationale: The Mantoux test requires the client to return within 48 to 72 hours for
accurate interpretation of induration. Failure to return invalidates the test. While
assessing the arm and asking about history are relevant, they are not the most critical
step. A history of BCG vaccination may cause a false positive, but the test can still be
administered and interpreted based on CDC guidelines for high-risk individuals, making
the return visit the priority.
Question 2: A nurse is providing discharge teaching to a patient with a new
diagnosis of heart failure. Which statement by the patient indicates a correct
understanding of daily weights?
A. "I should weigh myself at the same time every day before breakfast."
B. "I will weigh myself every morning after drinking a glass of water."
C. "I need to weigh myself weekly to monitor for fluid retention."
D. "I should weigh myself in the evening to get the most accurate weight."
CORRECT ANSWER: A. "I should weigh myself at the same time every day
before breakfast."
Rationale: Daily weights are the most reliable indicator of fluid volume status in heart
failure. The patient should weigh themselves at the same time each day, using the same
scale, after voiding and before eating or drinking to ensure consistency and accuracy.
Question 3: During an eye assessment, a nurse shines a light into the client's
right eye and observes constriction of the left pupil. What is this response
called?
A. Direct light reflex
B. Accommodation reflex
,C. Consensual light reflex
D. Pupillary convergence
CORRECT ANSWER: C. Consensual light reflex
Rationale: The consensual light reflex is the simultaneous constriction of the
contralateral pupil when light is directed into one eye. The direct reflex refers to the
constriction of the same eye. Accommodation and convergence involve focusing on a
near object and are not tested with a simple light stimulus.
Question 4: A nurse is caring for a client who has a nasogastric (NG) tube
attached to low intermittent suction. Which assessment finding indicates that
the tube may be correctly placed?
A. The pH of the aspirate is 8.0.
B. The client has no complaints of nausea.
C. The aspirated fluid has a grassy green appearance.
D. The external marking at the nares has increased by 2 cm.
CORRECT ANSWER: C. The aspirated fluid has a grassy green appearance.
Rationale: Gastric aspirate typically has a grassy green, clear, or brownish appearance
with a pH of 4.0 or less. A pH of 8.0 indicates intestinal or respiratory placement. Lack
of nausea is not a definitive indicator of placement. An increase in external marking
suggests the tube has moved.
Question 5: A nurse is preparing to administer an intramuscular (IM) injection
in the ventrogluteal site. Which action is essential for correct landmarking of
this site?
A. Placing the palm of the hand over the greater trochanter.
B. Using the index and middle fingers to spread the skin taut.
C. Placing the heel of the hand on the iliac crest and pointing the thumb toward the
anterior superior iliac spine.
D. Measuring a hands-breadth below the acromion process.
CORRECT ANSWER: C. Placing the heel of the hand on the iliac crest and
pointing the thumb toward the anterior superior iliac spine.
Rationale: To locate the ventrogluteal site, the nurse places the heel of the hand on the
greater trochanter and points the index finger toward the anterior superior iliac spine,
forming a V-shape. The injection is given in the center of this V. Option A describes
locating the vastus lateralis.
Question 6: A client is receiving a blood transfusion and reports a sudden
onset of chills, low back pain, and flushing. What should be the nurse's
priority action?
A. Slow the transfusion rate to 50 mL/hr.
B. Stop the infusion and disconnect the blood tubing.
,C. Stop the infusion and maintain the IV line with normal saline.
D. Administer an antihistamine as a standing order.
CORRECT ANSWER: C. Stop the infusion and maintain the IV line with normal
saline.
Rationale: These symptoms indicate a possible acute hemolytic transfusion reaction.
The nurse must stop the transfusion immediately but keep the IV line open with normal
saline to maintain venous access and prepare for emergency medications if needed. The
blood tubing should not be disconnected, as the remainder must be sent to the blood
bank for analysis.
Question 7: A nurse is assessing a client’s cardiovascular status. Which finding
is a late sign of hypovolemic shock?
A. Thready, rapid pulse
B. Decreased urine output
C. Hypotension
D. Cool, clammy skin
CORRECT ANSWER: C. Hypotension
Rationale: In hypovolemic shock, the body compensates early by increasing heart rate
and peripheral vasoconstriction to maintain blood pressure. Hypotension is a late and
ominous sign because the compensatory mechanisms are overwhelmed. Tachycardia,
cool skin, and decreased urine output occur earlier.
Question 8: A client with a colostomy is concerned about odor. Which dietary
instruction should the nurse provide to help reduce odor?
A. Increase intake of eggs and fish.
B. Eat buttermilk, parsley, or yogurt.
C. Avoid all leafy green vegetables.
D. Increase intake of asparagus and onions.
CORRECT ANSWER: B. Eat buttermilk, parsley, or yogurt.
Rationale: Buttermilk, parsley, and yogurt are known to help reduce colostomy odor.
Eggs, fish, asparagus, and onions are foods that typically increase odor. Leafy green
vegetables do not universally increase odor and are important for nutrition.
Question 9: The nurse is performing a neurological assessment on a client.
Which cranial nerve is being tested when the nurse asks the client to shrug
their shoulders against resistance?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Accessory)
D. Cranial Nerve XII (Hypoglossal)
CORRECT ANSWER: C. Cranial Nerve XI (Accessory)
, Rationale: The spinal accessory nerve (CN XI) innervates the sternocleidomastoid and
trapezius muscles. Assessment involves asking the client to shrug their shoulders
(trapezius) and turn their head against resistance (sternocleidomastoid).
Question 10: A nurse is calculating the intake and output for a client over an 8-
hour shift. The client consumed 4 oz of juice, 8 oz of milk, 6 oz of tea, and had
90 mL of ice chips. How many total mL of intake should the nurse document?
A. 480 mL
B. 630 mL
C. 720 mL
D. 810 mL
CORRECT ANSWER: B. 630 mL
Rationale: 1 oz = 30 mL. Total fluid ounces = 4 + 8 + 6 = 18 oz. 18 oz x 30 mL = 540
mL. Ice chips are calculated as half their volume (90 mL / 2 = 45 mL). Total intake =
540 + 90 = 630 mL.
Question 11: A client is admitted with dehydration. Which laboratory value is
the most specific indicator of the client's fluid volume status?
A. Serum sodium
B. Serum potassium
C. Blood urea nitrogen (BUN) to creatinine ratio
D. Serum osmolarity
CORRECT ANSWER: C. Blood urea nitrogen (BUN) to creatinine ratio
Rationale: BUN and creatinine are both waste products, but BUN is more sensitive to
hydration status. A normal ratio is 10:1 to 20:1. In dehydration, the BUN rises
disproportionately to creatinine due to prerenal azotemia, causing the ratio to increase
above 20:1.
Question 12: A nurse is teaching a client about the proper use of a metered-
dose inhaler (MDI). Which action indicates that the client needs further
teaching?
A. The client shakes the inhaler before use.
B. The client exhales completely before placing the mouthpiece in the mouth.
C. The client holds the breath for 10 seconds after inhalation.
D. The client activates the inhaler at the start of inhalation.
CORRECT ANSWER: D. The client activates the inhaler at the start of
inhalation.
Rationale: The correct technique is to activate the inhaler AFTER starting a slow, deep
inhalation (not at the start) to ensure the medication is carried deep into the lungs.
Holding the breath for 10 seconds allows for optimal deposition.
Bachelor of Science in Nursing Prelicensure (Pre-
Nursing) Study Guide, Original Practice Questions &
Answers, Assessment Preparation, Comprehensive
Nursing Foundations Review, Patient Care, Nursing
Process, Safety, Communication, Professional
Nursing Concepts & Clinical Fundamentals
Question 1: A client who recently immigrated from a country with a high
prevalence of tuberculosis (TB) is scheduled for a Mantoux tuberculin skin test
(TST). Which nursing action is most critical prior to administering the test?
A. Assess the client’s arm for any rashes or lesions.
B. Ensure the client has not received the BCG vaccine.
C. Ask the client if they have a history of a positive TB test.
D. Verify the client’s ability to return for the reading in 48-72 hours.
CORRECT ANSWER: D. Verify the client’s ability to return for the reading in
48-72 hours.
Rationale: The Mantoux test requires the client to return within 48 to 72 hours for
accurate interpretation of induration. Failure to return invalidates the test. While
assessing the arm and asking about history are relevant, they are not the most critical
step. A history of BCG vaccination may cause a false positive, but the test can still be
administered and interpreted based on CDC guidelines for high-risk individuals, making
the return visit the priority.
Question 2: A nurse is providing discharge teaching to a patient with a new
diagnosis of heart failure. Which statement by the patient indicates a correct
understanding of daily weights?
A. "I should weigh myself at the same time every day before breakfast."
B. "I will weigh myself every morning after drinking a glass of water."
C. "I need to weigh myself weekly to monitor for fluid retention."
D. "I should weigh myself in the evening to get the most accurate weight."
CORRECT ANSWER: A. "I should weigh myself at the same time every day
before breakfast."
Rationale: Daily weights are the most reliable indicator of fluid volume status in heart
failure. The patient should weigh themselves at the same time each day, using the same
scale, after voiding and before eating or drinking to ensure consistency and accuracy.
Question 3: During an eye assessment, a nurse shines a light into the client's
right eye and observes constriction of the left pupil. What is this response
called?
A. Direct light reflex
B. Accommodation reflex
,C. Consensual light reflex
D. Pupillary convergence
CORRECT ANSWER: C. Consensual light reflex
Rationale: The consensual light reflex is the simultaneous constriction of the
contralateral pupil when light is directed into one eye. The direct reflex refers to the
constriction of the same eye. Accommodation and convergence involve focusing on a
near object and are not tested with a simple light stimulus.
Question 4: A nurse is caring for a client who has a nasogastric (NG) tube
attached to low intermittent suction. Which assessment finding indicates that
the tube may be correctly placed?
A. The pH of the aspirate is 8.0.
B. The client has no complaints of nausea.
C. The aspirated fluid has a grassy green appearance.
D. The external marking at the nares has increased by 2 cm.
CORRECT ANSWER: C. The aspirated fluid has a grassy green appearance.
Rationale: Gastric aspirate typically has a grassy green, clear, or brownish appearance
with a pH of 4.0 or less. A pH of 8.0 indicates intestinal or respiratory placement. Lack
of nausea is not a definitive indicator of placement. An increase in external marking
suggests the tube has moved.
Question 5: A nurse is preparing to administer an intramuscular (IM) injection
in the ventrogluteal site. Which action is essential for correct landmarking of
this site?
A. Placing the palm of the hand over the greater trochanter.
B. Using the index and middle fingers to spread the skin taut.
C. Placing the heel of the hand on the iliac crest and pointing the thumb toward the
anterior superior iliac spine.
D. Measuring a hands-breadth below the acromion process.
CORRECT ANSWER: C. Placing the heel of the hand on the iliac crest and
pointing the thumb toward the anterior superior iliac spine.
Rationale: To locate the ventrogluteal site, the nurse places the heel of the hand on the
greater trochanter and points the index finger toward the anterior superior iliac spine,
forming a V-shape. The injection is given in the center of this V. Option A describes
locating the vastus lateralis.
Question 6: A client is receiving a blood transfusion and reports a sudden
onset of chills, low back pain, and flushing. What should be the nurse's
priority action?
A. Slow the transfusion rate to 50 mL/hr.
B. Stop the infusion and disconnect the blood tubing.
,C. Stop the infusion and maintain the IV line with normal saline.
D. Administer an antihistamine as a standing order.
CORRECT ANSWER: C. Stop the infusion and maintain the IV line with normal
saline.
Rationale: These symptoms indicate a possible acute hemolytic transfusion reaction.
The nurse must stop the transfusion immediately but keep the IV line open with normal
saline to maintain venous access and prepare for emergency medications if needed. The
blood tubing should not be disconnected, as the remainder must be sent to the blood
bank for analysis.
Question 7: A nurse is assessing a client’s cardiovascular status. Which finding
is a late sign of hypovolemic shock?
A. Thready, rapid pulse
B. Decreased urine output
C. Hypotension
D. Cool, clammy skin
CORRECT ANSWER: C. Hypotension
Rationale: In hypovolemic shock, the body compensates early by increasing heart rate
and peripheral vasoconstriction to maintain blood pressure. Hypotension is a late and
ominous sign because the compensatory mechanisms are overwhelmed. Tachycardia,
cool skin, and decreased urine output occur earlier.
Question 8: A client with a colostomy is concerned about odor. Which dietary
instruction should the nurse provide to help reduce odor?
A. Increase intake of eggs and fish.
B. Eat buttermilk, parsley, or yogurt.
C. Avoid all leafy green vegetables.
D. Increase intake of asparagus and onions.
CORRECT ANSWER: B. Eat buttermilk, parsley, or yogurt.
Rationale: Buttermilk, parsley, and yogurt are known to help reduce colostomy odor.
Eggs, fish, asparagus, and onions are foods that typically increase odor. Leafy green
vegetables do not universally increase odor and are important for nutrition.
Question 9: The nurse is performing a neurological assessment on a client.
Which cranial nerve is being tested when the nurse asks the client to shrug
their shoulders against resistance?
A. Cranial Nerve IX (Glossopharyngeal)
B. Cranial Nerve X (Vagus)
C. Cranial Nerve XI (Accessory)
D. Cranial Nerve XII (Hypoglossal)
CORRECT ANSWER: C. Cranial Nerve XI (Accessory)
, Rationale: The spinal accessory nerve (CN XI) innervates the sternocleidomastoid and
trapezius muscles. Assessment involves asking the client to shrug their shoulders
(trapezius) and turn their head against resistance (sternocleidomastoid).
Question 10: A nurse is calculating the intake and output for a client over an 8-
hour shift. The client consumed 4 oz of juice, 8 oz of milk, 6 oz of tea, and had
90 mL of ice chips. How many total mL of intake should the nurse document?
A. 480 mL
B. 630 mL
C. 720 mL
D. 810 mL
CORRECT ANSWER: B. 630 mL
Rationale: 1 oz = 30 mL. Total fluid ounces = 4 + 8 + 6 = 18 oz. 18 oz x 30 mL = 540
mL. Ice chips are calculated as half their volume (90 mL / 2 = 45 mL). Total intake =
540 + 90 = 630 mL.
Question 11: A client is admitted with dehydration. Which laboratory value is
the most specific indicator of the client's fluid volume status?
A. Serum sodium
B. Serum potassium
C. Blood urea nitrogen (BUN) to creatinine ratio
D. Serum osmolarity
CORRECT ANSWER: C. Blood urea nitrogen (BUN) to creatinine ratio
Rationale: BUN and creatinine are both waste products, but BUN is more sensitive to
hydration status. A normal ratio is 10:1 to 20:1. In dehydration, the BUN rises
disproportionately to creatinine due to prerenal azotemia, causing the ratio to increase
above 20:1.
Question 12: A nurse is teaching a client about the proper use of a metered-
dose inhaler (MDI). Which action indicates that the client needs further
teaching?
A. The client shakes the inhaler before use.
B. The client exhales completely before placing the mouthpiece in the mouth.
C. The client holds the breath for 10 seconds after inhalation.
D. The client activates the inhaler at the start of inhalation.
CORRECT ANSWER: D. The client activates the inhaler at the start of
inhalation.
Rationale: The correct technique is to activate the inhaler AFTER starting a slow, deep
inhalation (not at the start) to ensure the medication is carried deep into the lungs.
Holding the breath for 10 seconds allows for optimal deposition.
