WGU D486 DFN1 TASK 1: GOVERNANCE,
RISK, AND COMPLIANCE QUESTIONS AND
CORRECT ANSWERS WITH DETAILED
RATIONALES
Table of Contents
Questions 150: ………………… Fundamentals & Safety
Questions 51100: ………………... Pharmacology & IV Therapy
Questions 101150:……………………………….. Medical Surgical (Cardiac & Respiratory)
Questions 151200: ………… MedicalSurgical (GI, Renal, Neuro)
Questions 201250: ………………………………… Maternal Newborn & Pediatrics
Questions 251300: …………………………………………………….. Psychiatric & Mental Health
Questions 301350:…………………………………………. Leadership, Management, & Community
Health
Questions 150: Fundamentals & Safety
Q1. A nurse is preparing to insert a nasogastric (NG) tube for a client. Which
action should the nurse take to verify proper placement of the tube before
initiating feeding?
A) Auscultate for air instilled into the tube.
,B) Measure the pH of the gastric aspirate.
C) Place the end of the tube in water to check for bubbling.
D) Observe the color of the aspirate.
Correct Answer: B
Rationale: Measuring the pH of gastric aspirate (which should be acidic, pH
04) is the most reliable bedside method to confirm NG tube placement.
Auscultation (A) is no longer recommended as a sole method due to false
positives. Checking for bubbling (C) indicates the tube is in the lungs. Color
(D) is not definitive.
Q2. A client is receiving continuous tube feeding via a nasogastric tube. The
nurse should place the client in which position to prevent aspiration?
A) Supine
B) Prone
C) Semi Fowler’s (45 degrees)
D) Trendelenburg
Correct Answer: C
Rationale: The semi Fowler’s position (head of bed elevated 3045 degrees) is
essential during tube feeding to prevent reflux and aspiration into the lungs.
Supine (A) and Trendelenburg (D) increase aspiration risk.
Q3. A client is on fall precautions. Which intervention is most important to
include in the client's plan of care?
A) Keeping the bed in the lowest position.
B) Placing the call light on the client's nondominant side.
C) Applying wrist restraints to prevent wandering.
,D) Keeping the room completely dark at night.
Correct Answer: A
Rationale: Keeping the bed in the lowest position minimizes injury if the client
attempts to get out of bed unassisted. The call light should be within reach on
the dominant side (B). Restraints (C) are a last resort. A nightlight should be
left on (D).
Q4. A nurse is assessing a client who has a stage III pressure ulcer. Which
characteristic is expected for this stage?
A) Nonblanchable erythema of intact skin.
B) Partialthickness skin loss with exposed dermis.
C) Fullthickness skin loss with visible subcutaneous fat.
D) Fullthickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: C
Rationale: Stage III involves fullthickness skin loss extending into
subcutaneous tissue, but bone, tendon, and muscle are not exposed. A is Stage
I, B is Stage II, and D is Stage IV (or unstageable).
Q5. A client is admitted with dehydration. Which assessment finding indicates
a positive response to oral fluid replacement therapy?
A) Increased urine specific gravity.
B) Decreased blood pressure.
C) Increased heart rate.
D) Increased urine output and stable vital signs.
, Correct Answer: D
Rationale: Adequate hydration is indicated by increased urine output (>30
ml/hr) and stable or improving vital signs. Urine specific gravity (A) should
decrease as the kidneys concentrate less. BP (B) should increase, and HR (C)
should decrease as fluid volume is restored.
Q6. The nurse is providing postoperative care to a client who had a right total
knee arthroplasty. Which action is a priority to prevent venous
thromboembolism (VTE)?
A) Apply sequential compression devices (SCDs).
B) Administer oral aspirin daily.
C) Encourage the client to cross their legs to promote circulation.
D) Keep the knee fully immobilized for 24 hours.
Correct Answer: A
Rationale: SCDs promote venous return and are a standard
nonpharmacological prophylaxis for VTE. Crossing legs (C) impedes venous
return. Aspirin (B) is not the primary anticoagulant for postop VTE
prophylaxis (Heparin/Lovenox is preferred). Immobilization (D) increases
risk.
Q7. A nurse is caring for a client with a new tracheostomy. Which action is
most appropriate when providing tracheostomy care?
A) Use sterile technique when suctioning.
B) Clean the inner cannula with tap water.
C) Change the tracheostomy ties once a week.
D) Keep the obturator at the bedside.
RISK, AND COMPLIANCE QUESTIONS AND
CORRECT ANSWERS WITH DETAILED
RATIONALES
Table of Contents
Questions 150: ………………… Fundamentals & Safety
Questions 51100: ………………... Pharmacology & IV Therapy
Questions 101150:……………………………….. Medical Surgical (Cardiac & Respiratory)
Questions 151200: ………… MedicalSurgical (GI, Renal, Neuro)
Questions 201250: ………………………………… Maternal Newborn & Pediatrics
Questions 251300: …………………………………………………….. Psychiatric & Mental Health
Questions 301350:…………………………………………. Leadership, Management, & Community
Health
Questions 150: Fundamentals & Safety
Q1. A nurse is preparing to insert a nasogastric (NG) tube for a client. Which
action should the nurse take to verify proper placement of the tube before
initiating feeding?
A) Auscultate for air instilled into the tube.
,B) Measure the pH of the gastric aspirate.
C) Place the end of the tube in water to check for bubbling.
D) Observe the color of the aspirate.
Correct Answer: B
Rationale: Measuring the pH of gastric aspirate (which should be acidic, pH
04) is the most reliable bedside method to confirm NG tube placement.
Auscultation (A) is no longer recommended as a sole method due to false
positives. Checking for bubbling (C) indicates the tube is in the lungs. Color
(D) is not definitive.
Q2. A client is receiving continuous tube feeding via a nasogastric tube. The
nurse should place the client in which position to prevent aspiration?
A) Supine
B) Prone
C) Semi Fowler’s (45 degrees)
D) Trendelenburg
Correct Answer: C
Rationale: The semi Fowler’s position (head of bed elevated 3045 degrees) is
essential during tube feeding to prevent reflux and aspiration into the lungs.
Supine (A) and Trendelenburg (D) increase aspiration risk.
Q3. A client is on fall precautions. Which intervention is most important to
include in the client's plan of care?
A) Keeping the bed in the lowest position.
B) Placing the call light on the client's nondominant side.
C) Applying wrist restraints to prevent wandering.
,D) Keeping the room completely dark at night.
Correct Answer: A
Rationale: Keeping the bed in the lowest position minimizes injury if the client
attempts to get out of bed unassisted. The call light should be within reach on
the dominant side (B). Restraints (C) are a last resort. A nightlight should be
left on (D).
Q4. A nurse is assessing a client who has a stage III pressure ulcer. Which
characteristic is expected for this stage?
A) Nonblanchable erythema of intact skin.
B) Partialthickness skin loss with exposed dermis.
C) Fullthickness skin loss with visible subcutaneous fat.
D) Fullthickness tissue loss with exposed bone, tendon, or muscle.
Correct Answer: C
Rationale: Stage III involves fullthickness skin loss extending into
subcutaneous tissue, but bone, tendon, and muscle are not exposed. A is Stage
I, B is Stage II, and D is Stage IV (or unstageable).
Q5. A client is admitted with dehydration. Which assessment finding indicates
a positive response to oral fluid replacement therapy?
A) Increased urine specific gravity.
B) Decreased blood pressure.
C) Increased heart rate.
D) Increased urine output and stable vital signs.
, Correct Answer: D
Rationale: Adequate hydration is indicated by increased urine output (>30
ml/hr) and stable or improving vital signs. Urine specific gravity (A) should
decrease as the kidneys concentrate less. BP (B) should increase, and HR (C)
should decrease as fluid volume is restored.
Q6. The nurse is providing postoperative care to a client who had a right total
knee arthroplasty. Which action is a priority to prevent venous
thromboembolism (VTE)?
A) Apply sequential compression devices (SCDs).
B) Administer oral aspirin daily.
C) Encourage the client to cross their legs to promote circulation.
D) Keep the knee fully immobilized for 24 hours.
Correct Answer: A
Rationale: SCDs promote venous return and are a standard
nonpharmacological prophylaxis for VTE. Crossing legs (C) impedes venous
return. Aspirin (B) is not the primary anticoagulant for postop VTE
prophylaxis (Heparin/Lovenox is preferred). Immobilization (D) increases
risk.
Q7. A nurse is caring for a client with a new tracheostomy. Which action is
most appropriate when providing tracheostomy care?
A) Use sterile technique when suctioning.
B) Clean the inner cannula with tap water.
C) Change the tracheostomy ties once a week.
D) Keep the obturator at the bedside.
