WGU D453 Advanced Nursing Skills Exam Newest Version UP-TO-DATE EXAM
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sECTION 1: SAFETY, INFECTION CONTROL & VITAL SIGNS
Questions 1–25
Question 1
Using the principles of standard precautions, the nurse would wear gloves in which
nursing intervention?
A) Providing a back massage
B) Feeding a client
C) Providing hair care
D) Providing oral hygiene
Correct Answer: D
Rationale: Standard precautions assume all body fluids (except sweat) are potentially
infectious. Oral hygiene involves contact with mucous membranes and saliva, requiring
glove use to prevent exposure to pathogens. Back massage, feeding, and hair care do
not involve contact with body fluids.
Question 2
A nurse obtained a client's pulse and found the rate to be above normal. The nurse
documents this finding as:
A) Tachypnea
B) Hyperpyrexia
,C) Arrhythmia
D) Tachycardia
Correct Answer: D
Rationale: Tachycardia refers to an abnormally fast resting heart rate (>100 bpm in
adults). Tachypnea is rapid breathing, hyperpyrexia is extremely high fever, and
arrhythmia is an irregular heartbeat rhythm.
Question 3
A client who is unconscious needs frequent mouth care. When performing mouth care,
the best position for the client is:
A) Fowler's position
B) Side-lying
C) Supine
D) Trendelenburg
Correct Answer: B
Rationale: The side-lying position allows fluids used during oral care to drain out of
the mouth by gravity, preventing aspiration into the lungs—a critical safety measure for
unconscious patients who cannot protect their own airway.
Question 4
Which of the following actions should the nurse take to use a wide base of support
when assisting a client to get up in a chair?
A) Bend at the waist and place arms under the client's arms and lift
B) Face the client, bend knees and place hands on client's forearm and lift
C) Spread his or her feet apart
D) Tighten his or her pelvic muscles
Correct Answer: C
,Rationale: Using a wide base of support means spreading the feet apart to increase
stability and lower the center of gravity, reducing the risk of back injury when lifting or
transferring a patient. Bending at the waist is dangerous; proper body mechanics involve
bending at the knees.
Question 5
A nurse is preparing to perform a sterile wound irrigation. Which action demonstrates
correct sterile technique?
A) Pouring the irrigating solution into a sterile basin held at waist level
B) Opening the sterile drape with the inner surface facing away from the body
C) Holding the bottle of sterile solution so that it drips directly onto the sterile field
D) Setting up the sterile field and then leaving the room to obtain supplies
Correct Answer: B
Rationale: When opening a sterile drape, the top flap should be opened away from
the body, and the inner surface (the part that will face up) should not be touched or
exposed to unsterile surfaces. Pouring solution should be done into a sterile basin held
above waist level, not at waist level. The bottle should not drip onto the field as this can
cause contamination. Leaving the sterile field unattended compromises sterility.
Question 6
A patient with a tracheostomy tube suddenly develops respiratory distress, absent
breath sounds on the right side, and tracheal deviation to the left. What is the priority
nursing action?
A) Suction the tracheostomy tube
B) Prepare for emergency needle decompression
C) Increase oxygen flow to 15 L/min via tracheostomy mask
D) Call a rapid response and place the patient in high Fowler's position
Correct Answer: B
Rationale: The signs indicate a tension pneumothorax (absent breath sounds,
tracheal deviation away from the affected side—here deviation to left suggests right-
, sided tension pneumothorax). This is a life-threatening emergency. Needle
decompression (second intercostal space, midclavicular line) is the priority to relieve
pressure. Suctioning or repositioning will not resolve the tension.
Question 7
A nurse is administering a blood transfusion of packed red blood cells. Fifteen minutes
after starting, the patient reports chills, low back pain, and feels "flushed." Which action
should the nurse take first?
A) Stop the transfusion
B) Slow the infusion rate to 10 mL/hr
C) Administer diphenhydramine as prescribed
D) Notify the provider
Correct Answer: A
Rationale: These symptoms suggest an acute hemolytic transfusion reaction. The first
action is to stop the transfusion immediately to prevent further reaction. Then
disconnect the tubing, keep IV access with normal saline, notify the provider, and send
the blood bag and tubing to the lab. Slowing or medicating delays critical action.
Question 8
A nurse is preparing to transfer a patient from bed to stretcher. Which action
demonstrates proper body mechanics?
A) Bending at the waist to lift the patient
B) Keeping feet together for stability
C) Using the large muscles of the legs and keeping the back straight
D) Twisting the torso while pulling the patient
Correct Answer: C
Rationale: Proper body mechanics require using strong leg muscles rather than back
muscles to prevent injury. The back should remain straight, feet should be shoulder-
width apart for stability, and the nurse should avoid twisting.
QUESTIONS AND 100% ACCURATE SOLUTIONS | Question And VERIFIED ANSWERS -
INSTANT PDF DOWNLOAD.
sECTION 1: SAFETY, INFECTION CONTROL & VITAL SIGNS
Questions 1–25
Question 1
Using the principles of standard precautions, the nurse would wear gloves in which
nursing intervention?
A) Providing a back massage
B) Feeding a client
C) Providing hair care
D) Providing oral hygiene
Correct Answer: D
Rationale: Standard precautions assume all body fluids (except sweat) are potentially
infectious. Oral hygiene involves contact with mucous membranes and saliva, requiring
glove use to prevent exposure to pathogens. Back massage, feeding, and hair care do
not involve contact with body fluids.
Question 2
A nurse obtained a client's pulse and found the rate to be above normal. The nurse
documents this finding as:
A) Tachypnea
B) Hyperpyrexia
,C) Arrhythmia
D) Tachycardia
Correct Answer: D
Rationale: Tachycardia refers to an abnormally fast resting heart rate (>100 bpm in
adults). Tachypnea is rapid breathing, hyperpyrexia is extremely high fever, and
arrhythmia is an irregular heartbeat rhythm.
Question 3
A client who is unconscious needs frequent mouth care. When performing mouth care,
the best position for the client is:
A) Fowler's position
B) Side-lying
C) Supine
D) Trendelenburg
Correct Answer: B
Rationale: The side-lying position allows fluids used during oral care to drain out of
the mouth by gravity, preventing aspiration into the lungs—a critical safety measure for
unconscious patients who cannot protect their own airway.
Question 4
Which of the following actions should the nurse take to use a wide base of support
when assisting a client to get up in a chair?
A) Bend at the waist and place arms under the client's arms and lift
B) Face the client, bend knees and place hands on client's forearm and lift
C) Spread his or her feet apart
D) Tighten his or her pelvic muscles
Correct Answer: C
,Rationale: Using a wide base of support means spreading the feet apart to increase
stability and lower the center of gravity, reducing the risk of back injury when lifting or
transferring a patient. Bending at the waist is dangerous; proper body mechanics involve
bending at the knees.
Question 5
A nurse is preparing to perform a sterile wound irrigation. Which action demonstrates
correct sterile technique?
A) Pouring the irrigating solution into a sterile basin held at waist level
B) Opening the sterile drape with the inner surface facing away from the body
C) Holding the bottle of sterile solution so that it drips directly onto the sterile field
D) Setting up the sterile field and then leaving the room to obtain supplies
Correct Answer: B
Rationale: When opening a sterile drape, the top flap should be opened away from
the body, and the inner surface (the part that will face up) should not be touched or
exposed to unsterile surfaces. Pouring solution should be done into a sterile basin held
above waist level, not at waist level. The bottle should not drip onto the field as this can
cause contamination. Leaving the sterile field unattended compromises sterility.
Question 6
A patient with a tracheostomy tube suddenly develops respiratory distress, absent
breath sounds on the right side, and tracheal deviation to the left. What is the priority
nursing action?
A) Suction the tracheostomy tube
B) Prepare for emergency needle decompression
C) Increase oxygen flow to 15 L/min via tracheostomy mask
D) Call a rapid response and place the patient in high Fowler's position
Correct Answer: B
Rationale: The signs indicate a tension pneumothorax (absent breath sounds,
tracheal deviation away from the affected side—here deviation to left suggests right-
, sided tension pneumothorax). This is a life-threatening emergency. Needle
decompression (second intercostal space, midclavicular line) is the priority to relieve
pressure. Suctioning or repositioning will not resolve the tension.
Question 7
A nurse is administering a blood transfusion of packed red blood cells. Fifteen minutes
after starting, the patient reports chills, low back pain, and feels "flushed." Which action
should the nurse take first?
A) Stop the transfusion
B) Slow the infusion rate to 10 mL/hr
C) Administer diphenhydramine as prescribed
D) Notify the provider
Correct Answer: A
Rationale: These symptoms suggest an acute hemolytic transfusion reaction. The first
action is to stop the transfusion immediately to prevent further reaction. Then
disconnect the tubing, keep IV access with normal saline, notify the provider, and send
the blood bag and tubing to the lab. Slowing or medicating delays critical action.
Question 8
A nurse is preparing to transfer a patient from bed to stretcher. Which action
demonstrates proper body mechanics?
A) Bending at the waist to lift the patient
B) Keeping feet together for stability
C) Using the large muscles of the legs and keeping the back straight
D) Twisting the torso while pulling the patient
Correct Answer: C
Rationale: Proper body mechanics require using strong leg muscles rather than back
muscles to prevent injury. The back should remain straight, feet should be shoulder-
width apart for stability, and the nurse should avoid twisting.
