WGU D439
Objective Assessment
(2 Full Exams Set)
(Foundations of Nursing)
Actual Questions with Verified Answers
Pass the Exam with Confidence
What You Will Get:
➢140 Questions with correct answers.
➢Expert Rationales included.
➢OA Study Guide Questions
, Preview Pages Below
Get the Complete PDF After Purchase
"If you require further clarification or in need of any study resources, feel
free to Message me."
Digital preview sample
,Contents
D439 OA Exam Set 1 ............................................................. 2
D439 OA Exam Set 2 ........................................................... 37
D439 OA Study Guide ......................................................... 66
D439 OA Exam Set 1
1. A child has experienced several episodes of vomiting. After the nurse reviews
the need to provide only clear liquids, the parent of the child reports making clear
liquid popsicles out of flavored gelatin for the child. Which information should the
nurse obtain about the popsicles?
A. Whether they contain artificial coloring or sweeteners
B. Whether they contain fruit or pulp
C. The temperature at which they were frozen
D. The brand of gelatin used to make the popsicles
Correct Answer: B
Rationale: Clear liquid diets consist of transparent, residue-free fluids that leave
minimal gastric content and are easily digested. The critical concern with homemade
gelatin popsicles is whether they contain fruit pieces, pulp, or other solid additives that
would violate the clear liquid requirement. Fruit or pulp increases gastric residue,
potentially worsening vomiting or delaying gastric emptying. Plain gelatin (which
becomes liquid at body temperature) is acceptable. Options A, C, and D are irrelevant to
the classification of the popsicle as a clear liquid and do not affect its suitability for a
child with vomiting.
2. The nurse is caring for a client with type 2 diabetes mellitus who had surgery
for a large bowel resection with a colostomy placement. The client has now
developed hyperglycemia which requires self-injections of insulin after
,discharge. When designing the postoperative plan of care, which outcome
statement should the nurse use?
A. The client will demonstrate ability to change the ostomy bag in two days
B. The client will adhere to the medication regimen after discharge
C. The client will achieve a hemoglobin A1c of less than 7% within 3 months
D. The client will list three signs of hypoglycemia before discharge
Correct Answer: B
Rationale: The outcome statement must be specific, measurable, achievable, relevant,
and time-bound (SMART). "The client will adhere to the medication regimen after
discharge" addresses the newly prescribed insulin therapy, is measurable through
follow-up assessment, achievable with education, directly relevant to the hyperglycemia
management, and time-bound to the post-discharge period. Option A focuses on ostomy
care rather than the new insulin requirement; Option C is a long-term goal beyond the
immediate postoperative plan; Option D is relevant but secondary to medication
adherence for a client newly requiring insulin.
3. A 16-year-old emancipated client is being seen in the emergency department
following a minor automobile accident. The client's parents arrive and are asking
questions about the client's laboratory results. Which response is best for the
nurse to provide?
A. "I can only give medical information to your child because they are legally an adult."
B. "I will share the results with you since you are the parents."
C. "I need your child's written consent before I can discuss any medical information with
you."
D. "The healthcare provider will discuss the results with all of you together."
Correct Answer: A
Rationale: An emancipated minor has the legal status of an adult for healthcare
decision-making and privacy rights under HIPAA. Emancipation grants the minor
autonomy to consent to treatment, access medical records, and control the disclosure of
protected health information (PHI). The nurse must respect this legal status and direct
information requests to the emancipated client. Option B violates HIPAA and the
emancipated minor's privacy rights; Option C is incorrect because emancipated minors
control their own information disclosure—they do not require parental consent; Option D
inappropriately includes parents without the minor's authorization.
,4. The nurse is caring for a client with a history of neuropathy who reports
increasing numbness and tingling in the lower extremities. Which problem should
the nurse determine is the priority for promoting foot care at this time?
A. Risk for falls related to sensory deficit
B. Risk for impaired skin integrity
C. Activity intolerance related to pain
D. Disturbed body image related to foot deformities
Correct Answer: B
Rationale: Peripheral neuropathy causes loss of protective sensation (LOPS), meaning
the client cannot feel pain, pressure, temperature, or trauma to the feet. This sensory
deficit leads to unrecognized injuries (blisters, cuts, burns, pressure points) that
progress to infection, ulceration, and potential amputation—particularly in diabetic
patients. Risk for impaired skin integrity is the priority nursing diagnosis because it has
the most direct, severe, and preventable consequences. While risk for falls (A) is
relevant, it is secondary to the limb-threatening risk of skin breakdown. Options C and D
are not supported by the assessment data provided.
5. The nurse enters a client's room to perform a physical assessment and finds
the client crying. Which response is best for the nurse to provide?
A. "I can see you're upset. I'll come back later when you're feeling better."
B. While touching the client's forearm, asks, "Would you like to talk about it?"
C. "Crying won't solve anything. Let's focus on your physical assessment."
D. "I know exactly how you feel. I went through the same thing last year."
Correct Answer: B
Rationale: This response demonstrates therapeutic communication: appropriate touch
(forearm touch conveys empathy and presence without being intrusive), an open-ended
question that invites expression without pressure, and respect for the client's autonomy
to share or decline. It establishes therapeutic rapport and allows the nurse to assess
emotional status. Option A abandons the client in distress; Option C invalidates
emotions and is dismissive; Option D is non-therapeutic self-disclosure that shifts focus
to the nurse and assumes identical experiences.
6. The nurse is interviewing a client with lower abdominal pain and dysuria and
needs to question the client about sexual activity. Which approach is best for the
nurse to use?
,A. Ask the UAP to continue the bath but monitor the client closely.
B. Remove the basin of water from the client’s bed immediately.
C. Check the client’s temperature before continuing the bath.
D. Document the UAP’s technique in the client’s medical record.
Correct Answer: B. Remove the basin of water from the client’s bed immediately.
Rationale:
The priority nursing action is to protect the client from injury. A confused and lethargic
client may not be able to report discomfort, pain, or excessive heat, placing the client at
high risk for burns, scalding, or accidental injury. A basin of water placed on the bed also
increases the risk of spills and unsafe positioning. The nurse should intervene
immediately to remove the hazard before providing teaching to the UAP.
Rationale for Incorrect Options:
A. Continuing the bath does not address the immediate safety risk.
C. Checking temperature may be appropriate in general care, but it is not the priority
action in this unsafe situation.
D. Documentation may be needed later, but immediate intervention is required first.
69. Which assessment is most important for the nurse to perform prior to the
application of a heating pad?
A. Client’s degree of neurosensory impairment.
B. Client’s preferred temperature setting.
C. Client’s most recent oral temperature.
D. Client’s ability to turn independently in bed.
Correct Answer: A. Client’s degree of neurosensory impairment.
Rationale:
Before applying heat therapy, the nurse must assess the client’s ability to feel
temperature and pain. Clients with decreased sensation, neuropathy, altered level of
consciousness, or impaired circulation are at increased risk for burns because they may
not recognize when the heating pad is too hot or has been applied too long.
Rationale for Incorrect Options:
B. Client preference is not the priority because safety depends on sensory assessment.
C. Oral temperature does not determine whether the client can safely tolerate local heat
therapy.
D. Mobility is important, but neurosensory status is the most important assessment
before heat application.
,70. After an intravenous antibiotic is started, the nurse determines that the
medication is not prescribed for the client and stops the infusion. Which action
should the nurse implement next?
A. Notify the healthcare provider.
B. Restart the infusion at a slower rate.
C. Discard the medication and continue routine care.
D. Ask another nurse to verify the medication order.
Correct Answer: A. Notify the healthcare provider.
Rationale:
After stopping an incorrectly administered medication, the nurse must notify the
healthcare provider immediately. This is a medication error, and the client must be
assessed for potential adverse effects. The provider may prescribe monitoring,
laboratory tests, treatment, or additional interventions depending on the medication,
dose, and amount infused.
Rationale for Incorrect Options:
B. Restarting the infusion would continue an unsafe medication error.
C. Discarding the medication without notification fails to address client safety and
reporting requirements.
D. Verification may help clarify the error, but after the medication has already been
started and stopped, the healthcare provider must be notified next.
,Correct Answer: B
Rationale: Proper catheterization technique for uncircumcised males requires gentle
foreskin retraction to expose the glans and meatus. Cleaning is performed in a circular
motion from the meatus outward (centripetal) using a new, sterile gauze pad or swab for
each stroke to prevent recontamination. This follows surgical scrub principles: clean
from the cleanest area (meatus) to the less clean area (periphery). Option A violates
aseptic technique by reusing pads and using back-and-forth motion; Option C cleans
the wrong area and wrong direction; Option D is not standard practice and may interfere
with catheter insertion.
56. The priority nursing intervention for a female with vaginal bleeding is:
A. Safe sex protection education
B. Assess the amount, color, and consistency of bleeding
C. Administer hormonal therapy to stop the bleeding
D. Prepare the client for emergency surgical intervention
Correct Answer: A
Rationale: Safe sex protection education is the priority intervention for vaginal bleeding
when the underlying cause may be sexually transmitted infection (STI), trauma from
intercourse, or early pregnancy complications. Providing education about barrier
protection (condoms), STI prevention, and when to seek medical care addresses
immediate health promotion and prevents further complications. While assessment (B)
is important, the question context suggests a focus on preventive education. Options C
and D are medical interventions beyond nursing scope and require provider orders.
57. A patient with a laceration to the liver, fractured rib, and fused femur requires
which exercise intervention?
A. Active range of motion exercises for all extremities
B. Isometric exercise/quad flexing, hold for 10 seconds, repeat 8–10 times
C. Passive range of motion exercises performed by the physical therapist
D. Weight-bearing exercises on the unaffected leg only
Correct Answer: B
Rationale: With multiple traumatic injuries including liver laceration, rib fracture, and
femur fusion, the patient is on prolonged bed rest with restricted mobility. Isometric
exercises (muscle contraction without joint movement) maintain muscle strength,
prevent atrophy, and improve circulation without compromising fracture fixation or
,causing pain from rib/liver injury. Quad sets (quadriceps flexing), held for 10 seconds
and repeated 8–10 times, are standard isometric exercises for immobilized patients.
Active ROM (A) may be contraindicated due to pain and injury; passive ROM (C) does
not maintain muscle strength; weight-bearing (D) is contraindicated with femur fusion.
58. A client with a family history of cardiac disease is seeking information to
control risk factors. Which lifestyle modification is most important for the nurse
to encourage?
A. Begin a high-protein diet
B. Increase daily sodium intake
C. Stop smoking
D. Limit fluid intake
Correct Answer: C. Stop smoking
Rationale: Smoking cessation is one of the most important lifestyle modifications for
reducing cardiovascular risk. Smoking damages blood vessels, increases blood
pressure, decreases oxygen delivery, and increases the risk of coronary artery disease,
stroke, and peripheral vascular disease. While diet and exercise are also important,
stopping smoking has a major direct impact on cardiac risk reduction.
59. The nurse observes a decrease in a client's level of consciousness. Which
vital sign should the nurse obtain first?
A. Temperature
B. Respiratory rate
C. Blood pressure
D. Pain level
Correct Answer: B. Respiratory rate
Rationale: A decreased level of consciousness can indicate impaired oxygenation or
ventilation. The nurse should first assess the respiratory rate because inadequate
breathing can quickly lead to hypoxia and further neurologic decline. Airway and
breathing are always priority assessments when a client’s mental status changes.
60. CASE STUDY: History and Physical: The client is a 44-year-old with cerebral
palsy who is non-verbal and has a severe intellectual disability. He requires total
, care at home, which is provided by his two sisters, a home health nurse, and an
unlicensed home health aide. The client is currently in the hospital for a lower
respiratory infection. Identify from the choices area to specify which condition
the client is most likely experiencing, two actions the nurse should take to
address that condition, and two parameters the nurse should monitor to assess
the client's progress.
A. Functional urinary incontinence; encourage independent toileting; monitor skin turgor
and blood glucose
B. Overflow urinary incontinence; provide skin care; place an incontinence containment
product under the client; monitor intake and output and post-void residual
C. Stress urinary incontinence; teach pelvic floor exercises; restrict oral fluids; monitor
pulse and weight
D. Urge urinary incontinence; administer diuretics; encourage caffeine intake; monitor
oxygen saturation and bowel sounds
Correct Answer: B. Overflow urinary incontinence; provide skin care; place an
incontinence containment product under the client; monitor intake and output
and post-void residual
Rationale: The client is at risk for overflow urinary incontinence due to neurologic
impairment, immobility, and inability to communicate needs. Priority nursing actions
include protecting skin integrity and using an appropriate containment product to
prevent moisture-associated skin breakdown. Intake and output should be monitored to
evaluate urinary patterns, and post-void residual should be assessed to determine
whether the bladder is emptying effectively.
61. A client who had surgery 3 days ago is sitting with head of bed at 75 degrees
and requests to be repositioned. Which instruction is most important for the
nurse to provide to the unlicensed assistive personnel (UAP)?
A. Keep the head of the bed elevated while pulling the client upward
B. Lower the bed prior to helping the client move up in bed
C. Ask the client to hold their breath during repositioning
D. Place the client in a side-lying position before moving them
Correct Answer: B. Lower the bed prior to helping the client move up in bed
Rationale: The nurse should instruct the UAP to lower the head of the bed before
helping the client move upward. This decreases the effect of gravity, reduces friction
and shearing forces, and helps prevent injury to the client’s skin and surgical area.
Proper body mechanics and safe positioning are especially important after surgery.
Objective Assessment
(2 Full Exams Set)
(Foundations of Nursing)
Actual Questions with Verified Answers
Pass the Exam with Confidence
What You Will Get:
➢140 Questions with correct answers.
➢Expert Rationales included.
➢OA Study Guide Questions
, Preview Pages Below
Get the Complete PDF After Purchase
"If you require further clarification or in need of any study resources, feel
free to Message me."
Digital preview sample
,Contents
D439 OA Exam Set 1 ............................................................. 2
D439 OA Exam Set 2 ........................................................... 37
D439 OA Study Guide ......................................................... 66
D439 OA Exam Set 1
1. A child has experienced several episodes of vomiting. After the nurse reviews
the need to provide only clear liquids, the parent of the child reports making clear
liquid popsicles out of flavored gelatin for the child. Which information should the
nurse obtain about the popsicles?
A. Whether they contain artificial coloring or sweeteners
B. Whether they contain fruit or pulp
C. The temperature at which they were frozen
D. The brand of gelatin used to make the popsicles
Correct Answer: B
Rationale: Clear liquid diets consist of transparent, residue-free fluids that leave
minimal gastric content and are easily digested. The critical concern with homemade
gelatin popsicles is whether they contain fruit pieces, pulp, or other solid additives that
would violate the clear liquid requirement. Fruit or pulp increases gastric residue,
potentially worsening vomiting or delaying gastric emptying. Plain gelatin (which
becomes liquid at body temperature) is acceptable. Options A, C, and D are irrelevant to
the classification of the popsicle as a clear liquid and do not affect its suitability for a
child with vomiting.
2. The nurse is caring for a client with type 2 diabetes mellitus who had surgery
for a large bowel resection with a colostomy placement. The client has now
developed hyperglycemia which requires self-injections of insulin after
,discharge. When designing the postoperative plan of care, which outcome
statement should the nurse use?
A. The client will demonstrate ability to change the ostomy bag in two days
B. The client will adhere to the medication regimen after discharge
C. The client will achieve a hemoglobin A1c of less than 7% within 3 months
D. The client will list three signs of hypoglycemia before discharge
Correct Answer: B
Rationale: The outcome statement must be specific, measurable, achievable, relevant,
and time-bound (SMART). "The client will adhere to the medication regimen after
discharge" addresses the newly prescribed insulin therapy, is measurable through
follow-up assessment, achievable with education, directly relevant to the hyperglycemia
management, and time-bound to the post-discharge period. Option A focuses on ostomy
care rather than the new insulin requirement; Option C is a long-term goal beyond the
immediate postoperative plan; Option D is relevant but secondary to medication
adherence for a client newly requiring insulin.
3. A 16-year-old emancipated client is being seen in the emergency department
following a minor automobile accident. The client's parents arrive and are asking
questions about the client's laboratory results. Which response is best for the
nurse to provide?
A. "I can only give medical information to your child because they are legally an adult."
B. "I will share the results with you since you are the parents."
C. "I need your child's written consent before I can discuss any medical information with
you."
D. "The healthcare provider will discuss the results with all of you together."
Correct Answer: A
Rationale: An emancipated minor has the legal status of an adult for healthcare
decision-making and privacy rights under HIPAA. Emancipation grants the minor
autonomy to consent to treatment, access medical records, and control the disclosure of
protected health information (PHI). The nurse must respect this legal status and direct
information requests to the emancipated client. Option B violates HIPAA and the
emancipated minor's privacy rights; Option C is incorrect because emancipated minors
control their own information disclosure—they do not require parental consent; Option D
inappropriately includes parents without the minor's authorization.
,4. The nurse is caring for a client with a history of neuropathy who reports
increasing numbness and tingling in the lower extremities. Which problem should
the nurse determine is the priority for promoting foot care at this time?
A. Risk for falls related to sensory deficit
B. Risk for impaired skin integrity
C. Activity intolerance related to pain
D. Disturbed body image related to foot deformities
Correct Answer: B
Rationale: Peripheral neuropathy causes loss of protective sensation (LOPS), meaning
the client cannot feel pain, pressure, temperature, or trauma to the feet. This sensory
deficit leads to unrecognized injuries (blisters, cuts, burns, pressure points) that
progress to infection, ulceration, and potential amputation—particularly in diabetic
patients. Risk for impaired skin integrity is the priority nursing diagnosis because it has
the most direct, severe, and preventable consequences. While risk for falls (A) is
relevant, it is secondary to the limb-threatening risk of skin breakdown. Options C and D
are not supported by the assessment data provided.
5. The nurse enters a client's room to perform a physical assessment and finds
the client crying. Which response is best for the nurse to provide?
A. "I can see you're upset. I'll come back later when you're feeling better."
B. While touching the client's forearm, asks, "Would you like to talk about it?"
C. "Crying won't solve anything. Let's focus on your physical assessment."
D. "I know exactly how you feel. I went through the same thing last year."
Correct Answer: B
Rationale: This response demonstrates therapeutic communication: appropriate touch
(forearm touch conveys empathy and presence without being intrusive), an open-ended
question that invites expression without pressure, and respect for the client's autonomy
to share or decline. It establishes therapeutic rapport and allows the nurse to assess
emotional status. Option A abandons the client in distress; Option C invalidates
emotions and is dismissive; Option D is non-therapeutic self-disclosure that shifts focus
to the nurse and assumes identical experiences.
6. The nurse is interviewing a client with lower abdominal pain and dysuria and
needs to question the client about sexual activity. Which approach is best for the
nurse to use?
,A. Ask the UAP to continue the bath but monitor the client closely.
B. Remove the basin of water from the client’s bed immediately.
C. Check the client’s temperature before continuing the bath.
D. Document the UAP’s technique in the client’s medical record.
Correct Answer: B. Remove the basin of water from the client’s bed immediately.
Rationale:
The priority nursing action is to protect the client from injury. A confused and lethargic
client may not be able to report discomfort, pain, or excessive heat, placing the client at
high risk for burns, scalding, or accidental injury. A basin of water placed on the bed also
increases the risk of spills and unsafe positioning. The nurse should intervene
immediately to remove the hazard before providing teaching to the UAP.
Rationale for Incorrect Options:
A. Continuing the bath does not address the immediate safety risk.
C. Checking temperature may be appropriate in general care, but it is not the priority
action in this unsafe situation.
D. Documentation may be needed later, but immediate intervention is required first.
69. Which assessment is most important for the nurse to perform prior to the
application of a heating pad?
A. Client’s degree of neurosensory impairment.
B. Client’s preferred temperature setting.
C. Client’s most recent oral temperature.
D. Client’s ability to turn independently in bed.
Correct Answer: A. Client’s degree of neurosensory impairment.
Rationale:
Before applying heat therapy, the nurse must assess the client’s ability to feel
temperature and pain. Clients with decreased sensation, neuropathy, altered level of
consciousness, or impaired circulation are at increased risk for burns because they may
not recognize when the heating pad is too hot or has been applied too long.
Rationale for Incorrect Options:
B. Client preference is not the priority because safety depends on sensory assessment.
C. Oral temperature does not determine whether the client can safely tolerate local heat
therapy.
D. Mobility is important, but neurosensory status is the most important assessment
before heat application.
,70. After an intravenous antibiotic is started, the nurse determines that the
medication is not prescribed for the client and stops the infusion. Which action
should the nurse implement next?
A. Notify the healthcare provider.
B. Restart the infusion at a slower rate.
C. Discard the medication and continue routine care.
D. Ask another nurse to verify the medication order.
Correct Answer: A. Notify the healthcare provider.
Rationale:
After stopping an incorrectly administered medication, the nurse must notify the
healthcare provider immediately. This is a medication error, and the client must be
assessed for potential adverse effects. The provider may prescribe monitoring,
laboratory tests, treatment, or additional interventions depending on the medication,
dose, and amount infused.
Rationale for Incorrect Options:
B. Restarting the infusion would continue an unsafe medication error.
C. Discarding the medication without notification fails to address client safety and
reporting requirements.
D. Verification may help clarify the error, but after the medication has already been
started and stopped, the healthcare provider must be notified next.
,Correct Answer: B
Rationale: Proper catheterization technique for uncircumcised males requires gentle
foreskin retraction to expose the glans and meatus. Cleaning is performed in a circular
motion from the meatus outward (centripetal) using a new, sterile gauze pad or swab for
each stroke to prevent recontamination. This follows surgical scrub principles: clean
from the cleanest area (meatus) to the less clean area (periphery). Option A violates
aseptic technique by reusing pads and using back-and-forth motion; Option C cleans
the wrong area and wrong direction; Option D is not standard practice and may interfere
with catheter insertion.
56. The priority nursing intervention for a female with vaginal bleeding is:
A. Safe sex protection education
B. Assess the amount, color, and consistency of bleeding
C. Administer hormonal therapy to stop the bleeding
D. Prepare the client for emergency surgical intervention
Correct Answer: A
Rationale: Safe sex protection education is the priority intervention for vaginal bleeding
when the underlying cause may be sexually transmitted infection (STI), trauma from
intercourse, or early pregnancy complications. Providing education about barrier
protection (condoms), STI prevention, and when to seek medical care addresses
immediate health promotion and prevents further complications. While assessment (B)
is important, the question context suggests a focus on preventive education. Options C
and D are medical interventions beyond nursing scope and require provider orders.
57. A patient with a laceration to the liver, fractured rib, and fused femur requires
which exercise intervention?
A. Active range of motion exercises for all extremities
B. Isometric exercise/quad flexing, hold for 10 seconds, repeat 8–10 times
C. Passive range of motion exercises performed by the physical therapist
D. Weight-bearing exercises on the unaffected leg only
Correct Answer: B
Rationale: With multiple traumatic injuries including liver laceration, rib fracture, and
femur fusion, the patient is on prolonged bed rest with restricted mobility. Isometric
exercises (muscle contraction without joint movement) maintain muscle strength,
prevent atrophy, and improve circulation without compromising fracture fixation or
,causing pain from rib/liver injury. Quad sets (quadriceps flexing), held for 10 seconds
and repeated 8–10 times, are standard isometric exercises for immobilized patients.
Active ROM (A) may be contraindicated due to pain and injury; passive ROM (C) does
not maintain muscle strength; weight-bearing (D) is contraindicated with femur fusion.
58. A client with a family history of cardiac disease is seeking information to
control risk factors. Which lifestyle modification is most important for the nurse
to encourage?
A. Begin a high-protein diet
B. Increase daily sodium intake
C. Stop smoking
D. Limit fluid intake
Correct Answer: C. Stop smoking
Rationale: Smoking cessation is one of the most important lifestyle modifications for
reducing cardiovascular risk. Smoking damages blood vessels, increases blood
pressure, decreases oxygen delivery, and increases the risk of coronary artery disease,
stroke, and peripheral vascular disease. While diet and exercise are also important,
stopping smoking has a major direct impact on cardiac risk reduction.
59. The nurse observes a decrease in a client's level of consciousness. Which
vital sign should the nurse obtain first?
A. Temperature
B. Respiratory rate
C. Blood pressure
D. Pain level
Correct Answer: B. Respiratory rate
Rationale: A decreased level of consciousness can indicate impaired oxygenation or
ventilation. The nurse should first assess the respiratory rate because inadequate
breathing can quickly lead to hypoxia and further neurologic decline. Airway and
breathing are always priority assessments when a client’s mental status changes.
60. CASE STUDY: History and Physical: The client is a 44-year-old with cerebral
palsy who is non-verbal and has a severe intellectual disability. He requires total
, care at home, which is provided by his two sisters, a home health nurse, and an
unlicensed home health aide. The client is currently in the hospital for a lower
respiratory infection. Identify from the choices area to specify which condition
the client is most likely experiencing, two actions the nurse should take to
address that condition, and two parameters the nurse should monitor to assess
the client's progress.
A. Functional urinary incontinence; encourage independent toileting; monitor skin turgor
and blood glucose
B. Overflow urinary incontinence; provide skin care; place an incontinence containment
product under the client; monitor intake and output and post-void residual
C. Stress urinary incontinence; teach pelvic floor exercises; restrict oral fluids; monitor
pulse and weight
D. Urge urinary incontinence; administer diuretics; encourage caffeine intake; monitor
oxygen saturation and bowel sounds
Correct Answer: B. Overflow urinary incontinence; provide skin care; place an
incontinence containment product under the client; monitor intake and output
and post-void residual
Rationale: The client is at risk for overflow urinary incontinence due to neurologic
impairment, immobility, and inability to communicate needs. Priority nursing actions
include protecting skin integrity and using an appropriate containment product to
prevent moisture-associated skin breakdown. Intake and output should be monitored to
evaluate urinary patterns, and post-void residual should be assessed to determine
whether the bladder is emptying effectively.
61. A client who had surgery 3 days ago is sitting with head of bed at 75 degrees
and requests to be repositioned. Which instruction is most important for the
nurse to provide to the unlicensed assistive personnel (UAP)?
A. Keep the head of the bed elevated while pulling the client upward
B. Lower the bed prior to helping the client move up in bed
C. Ask the client to hold their breath during repositioning
D. Place the client in a side-lying position before moving them
Correct Answer: B. Lower the bed prior to helping the client move up in bed
Rationale: The nurse should instruct the UAP to lower the head of the bed before
helping the client move upward. This decreases the effect of gravity, reduces friction
and shearing forces, and helps prevent injury to the client’s skin and surgical area.
Proper body mechanics and safe positioning are especially important after surgery.
