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
, 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 ........................................................... 28
D439 OA Study Guide ......................................................... 53
D439 OA Exam Set 1
1. The nurse is caring for four clients. The client with which clinical manifestation
requires immediate attention from the nurse?
A. Respiratory rate of 25 breaths per minute after resting for 3 minutes after activity
B. Blood pressure of 140/90 mmHg
C. Heart rate of 88 beats per minute
D. Temperature of 99.2°F (37.3°C)
Correct Answer: A
Rationale: A respiratory rate of 25 breaths per minute is tachypneic and indicates
respiratory distress, especially after a 3-minute rest period following activity. The normal
adult respiratory rate is 12–20 breaths per minute. Elevated respiratory rate can signal
hypoxia, pain, anxiety, or impending respiratory failure and requires immediate nursing
assessment and intervention. Options B, C, and D represent values that are either
mildly elevated or within normal range and do not constitute an immediate priority.
2. The nurse places a client who had abdominal surgery in the semi-Fowler
position. The client states, "I prefer to lie flat when in bed. I feel like I am almost
sitting up." Which is an appropriate response by the nurse?
A. "Lying flat will increase your risk of developing a pulmonary embolism."
B. "Lifting your chest above your abdomen facilitates drainage in your wound."
C. "The semi-Fowler position is required for all postoperative abdominal clients."
D. "You can lie flat, but you must change positions every 15 minutes."
Correct Answer: B
,Rationale: The semi-Fowler position (head of bed elevated 30–45 degrees) is indicated
after abdominal surgery because it reduces tension on the incision, promotes wound
drainage, decreases intra-abdominal pressure, and facilitates respiratory expansion.
This response provides a clear, physiologically sound explanation that addresses the
client's concern while reinforcing the therapeutic benefit. Option A is fear-inducing and
not the primary rationale; Option C is authoritarian without explanation; Option D is
impractical and not evidence-based.
3. The nurse is educating a client who has just been prescribed a diuretic about
how to safely perform activities of daily living. Which statement should the nurse
include in the teaching?
A. "Take your diuretic at bedtime to avoid daytime urinary frequency."
B. "Change positions slowly to minimize orthostatic hypotension."
C. "Increase your sodium intake to replace what is lost in urine."
D. "Weigh yourself once weekly to monitor for weight gain."
Correct Answer: B
Rationale: Diuretics promote fluid loss, which can lead to volume depletion and
orthostatic hypotension—a drop in blood pressure upon standing that causes dizziness
and increases fall risk. Teaching the client to change positions slowly (supine → sitting
→ standing) allows the cardiovascular system time to compensate and prevents
syncope. Option A is incorrect because diuretics should be taken in the morning to
prevent nocturia; Option C is contraindicated as diuretics are often prescribed to reduce
sodium-related fluid retention; Option D is incorrect because clients should weigh
themselves daily, not weekly, to monitor for fluid retention or excessive loss.
4. The nurse recognizes that which statements made by a patient indicate an
understanding of behaviors that will promote sleep? (Select all that apply.)
A. "I will not watch television in bed."
B. "I will not drink caffeine later in the day."
C. "I will start to exercise regularly during the day."
D. "I will take a long nap every afternoon."
E. "I will keep my bedroom warm and brightly lit."
Correct Answers: A, B, C
Rationale: Sleep hygiene principles include: (A) avoiding stimulating activities such as
watching television in bed, which associates the bed with wakefulness rather than
,sleep; (B) avoiding caffeine (a stimulant) in the late afternoon or evening, as it has a
half-life of 3–5 hours and disrupts sleep onset; and (C) engaging in regular daytime
exercise, which promotes deeper sleep stages, provided it is not performed within 2–3
hours of bedtime. Option D is incorrect because long afternoon naps reduce sleep drive
and can cause sleep fragmentation at night. Option E is incorrect because a cool, dark
environment promotes melatonin secretion and optimal sleep quality.
5. Your patient is being discharged home and will be required to self-administer
injectable Heparin. You are observing the patient administer their scheduled dose
of Heparin to confirm that the patient knows how to do it correctly. What action by
the patient requires you to re-educate them about how to administer Heparin?
A. The patient cleanses the injection site with an alcohol swab and allows it to dry.
B. The patient injects the needle at a 90-degree angle into abdominal subcutaneous
tissue.
C. The patient injects the needle 1 inch away from the umbilicus.
D. The patient does not aspirate before injecting the medication.
Correct Answer: C
Rationale: Subcutaneous heparin should be administered in the abdominal fat layer at
least 2 inches (5 cm) away from the umbilicus to avoid vascular structures, ensure
proper absorption, and reduce the risk of bruising or hematoma. A 1-inch distance is
insufficient and places the patient at risk for complications. Option A is correct
technique; Option B is correct as heparin is given subcutaneously at 90 degrees in
patients with adequate abdominal adipose tissue; Option D is correct because
aspiration is not recommended for subcutaneous heparin administration as it may
increase bleeding risk and is unnecessary for this route.
6. A nurse caring for patients in a long-term care facility is often required to
collect urine specimens from patients for laboratory testing. Which techniques
for urine collection are performed correctly? (Select all that apply.)
A. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for
a urine culture.
B. The nurse discards the first urine of the day when performing a 24-hour urine
specimen collection on a patient.
C. The nurse obtains a clean-catch midstream specimen by cleaning the perineal area
from back to front.
D. The nurse clamps the indwelling catheter tubing for 15–30 minutes before obtaining
,Rationale:
The client’s heart rate has increased to 118 bpm, which may indicate worsening pain,
anxiety, physiological stress, or another postoperative complication. The nurse should
reassess for pain sources beyond the surgical site, use nonpharmacologic pain
interventions such as guided imagery, support safe mobility as tolerated, and consult
the surgeon if pain or abnormal vital signs persist. Postoperative clients require close
monitoring for changes that may indicate complications.
52. 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.
NURSE'S NOTES: Noted the client's clothes and sheets are wet. The client voided
approximately 75 mL of urine. The client's sister says that he usually wears adult
diapers at home as he is unable to communicate when he needs to void.
Correct Answer:
Potential Condition:
Overflow urinary incontinence
Actions to Take:
• Provide skin care
• Place an incontinence containment product under the client
Parameters to Monitor:
• Intake and output
• Skin integrity
• Post-void residual
Rationale:
The client is unable to communicate the need to void and has wet clothing and linens
with only a small amount of urine output, which may indicate overflow urinary
incontinence. Overflow incontinence can occur when the bladder does not empty
completely, causing leakage. The nurse should protect the skin from moisture-related
breakdown, use appropriate containment products, monitor intake and output, assess
skin integrity, and evaluate post-void residual to determine bladder emptying.
,53. The emergency department (ED) is caring for a 9-month-old male client who
was brought to the ED for nasal congestion, cough, fever, and difficulty
breathing. The client and his sister both attend daycare daily while their parents
are at work. The sister has been acting a bit run down but has not a fever or
oxygen deficit. For each statement, click to indicate whether the statement is true
or false.
Correct Answers:
• Hand washing needs to be performed when exiting the client's room. False
• This client requires contact and droplet precautions. True
• A gown and gloves should be worn any time there is potential for contact with
secretions. True
• A mask should always be worn when in the client's room. True
• This client would require a private room if admitted. True
Rationale:
A 9-month-old with fever, cough, nasal congestion, and difficulty breathing is at risk for a
contagious respiratory infection. Contact and droplet precautions are appropriate to
reduce transmission through respiratory secretions and contaminated surfaces. Staff
should use appropriate personal protective equipment, including mask, gown, and
gloves when exposure to secretions is possible. A private room is preferred to reduce
spread to other vulnerable clients. Hand hygiene is required when entering and exiting
the room, not only when exiting.
54. The patient is a 36-year-old female who is in the clinic today for insomnia. She
reports that she started having trouble sleeping over a year ago after her father's
death. She has no medical problems and has never had surgery. She takes an
oral contraceptive and a multivitamin daily. She does not smoke but drinks one to
two glasses of wine every evening. What other recommendations could the nurse
give to help the patient have better sleep? Select all that apply.
Correct Answers:
• Avoid alcohol in the evening
• Try to go to bed and awaken at the same time every day
• Avoid naps
,26. When identifying the goals to be included in a client's plan of care, the nurse
should take which action?
A. Review the priority nursing problems included in the plan of care
B. Consult with the healthcare provider to establish all goals
C. Write goals that are vague to allow for flexibility in care
D. Focus exclusively on physiological goals before addressing psychosocial needs
Correct Answer: A
Rationale: Goals (outcomes) in a nursing care plan must directly address the identified
nursing diagnoses and be derived from the priority problems. The nurse reviews the
prioritized diagnoses to ensure goals are specific, measurable, achievable, relevant,
and time-bound (SMART). For example, if "impaired gas exchange" is the priority
diagnosis, the goal might be "SpO2 ≥92% on 2 L NC within 24 hours." Option B is
incorrect because nursing goals are within independent nursing scope; Option C
contradicts the requirement for measurable, specific outcomes; Option D ignores the
holistic nature of nursing care and Maslow's integrated hierarchy.
27. A female client with metastatic breast cancer is admitted with shortness of
breath and pleural effusions. The client has a living will and the family is
requesting hospice information. Which information should the nurse provide
regarding hospice? (Select all that apply.)
A. Hospice services can be initiated prior to discharge
B. Family members can be involved in the plan of care
C. Hospice provides comfort, dignity, and emotional support
D. Hospice can be provided within the comforts of home
E. Hospice requires the client to stop all current cancer treatments
Correct Answers: A, B, C, D
Rationale: (A) Hospice services can begin in the hospital and continue through
discharge to home or a hospice facility, ensuring seamless care transitions. (B) Hospice
philosophy emphasizes family-centered care, with family members participating in care
planning, symptom management education, and bereavement support. (C) The hospice
mission focuses on palliation of physical symptoms (pain, dyspnea) while preserving
dignity and providing psychosocial/spiritual support. (D) Most hospice care
(approximately 70%) is delivered in the patient's home, assisted living, or nursing home.
Option E is incorrect—while hospice typically focuses on comfort rather than curative
treatment, some hospice programs allow concurrent palliative chemotherapy or
,radiation for symptom control (the Medicare hospice benefit has been modified to allow
some concurrent care in certain situations).
28. The nurse observes a practical nurse (PN) performing oral care on an
unconscious client. Which action by the PN indicates to the nurse the need for
additional training?
A. Places the client in a supine position
B. Uses a soft toothbrush and oral swabs
C. Performs oral care every 2 hours
D. Applies water-based mouth moisturizer after cleaning
Correct Answer: A
Rationale: An unconscious client must never be placed in supine position for oral care
because the risk of aspiration is severe. The correct position is side-lying (lateral) with
the head turned toward the dependent side, or semi-Fowler's if tolerated, to allow saliva
and secretions to drain by gravity rather than pooling in the posterior pharynx. Options
B, C, and D represent evidence-based oral care for unconscious patients: soft tools
prevent mucosal injury; frequent care (every 2–4 hours) prevents ventilator-associated
pneumonia and maintains oral health; water-based moisturizers prevent xerostomia
without aspiration risk.
29. The nurse is preparing to give an emergency sedative injection to an agitated
client. Which action by the nurse comprises a tort?
A. Administering the medication without verifying the client's identity
B. Placing a client in restraints without having a healthcare provider's order
C. Failing to document the medication administration immediately
D. Not obtaining informed consent for the emergency medication
Correct Answer: B
Rationale: A tort is a civil wrong that causes harm or loss. Placing a client in restraints
without a healthcare provider's order constitutes false imprisonment (a type of
intentional tort) and battery if physical force is used. Restraints require a specific
physician or provider order, indication documentation, time limits, and frequent
reassessment per The Joint Commission and CMS regulations. Emergency chemical
sedation (Option A) requires verification but may proceed without traditional consent
under implied consent/emergency doctrine; Option C is a documentation error but not
, necessarily a tort; Option D is incorrect because emergency treatment can proceed
under implied consent when the patient lacks capacity and delay would cause harm.
30. The nurse observes an unlicensed assistive personnel (UAP) feeding a client
who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which
action by the UAP should the nurse recognize indicates the need for additional
teaching?
A. Positions the head with the chin tilted slightly downward
B. Places food on the unaffected side of the mouth
C. Allows the client to self-feed using the unaffected hand
D. Ensures the client is sitting upright at 90 degrees
Correct Answer: A
Rationale: The correct positioning for a dysphagic patient during feeding is the chin-
tuck or chin-down position (tucking the chin down toward the chest), NOT tilting the
chin downward toward the neck in a flexed position. The chin-tuck narrows the airway
entrance, widens the vallecular space, and delays laryngeal elevation, thereby
protecting the airway and facilitating swallowing. "Chin tilted slightly downward" as
described suggests a flexed neck position that actually increases aspiration risk by
altering oropharyngeal alignment. Options B, C, and D are correct techniques: placing
food on the unaffected side utilizes intact sensation and motor function; self-feeding
promotes independence and oral motor coordination; and 90-degree upright positioning
uses gravity to assist bolus transit.
31. It is most important for the nurse to recalculate the Braden scale score for a
client who has developed which problem?
A. Urinary incontinence
B. Mild anxiety about hospitalization
C. Decreased appetite with meals
D. Request for a different roommate
Correct Answer: A
Rationale: The Braden Scale for Predicting Pressure Sore Risk assesses six
subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Urinary incontinence directly impacts the moisture subscale, which evaluates the
degree to which skin is exposed to moisture. Incontinence increases moisture exposure,
causing maceration, raising the pH of the skin, and increasing friction—significantly
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
, 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 ........................................................... 28
D439 OA Study Guide ......................................................... 53
D439 OA Exam Set 1
1. The nurse is caring for four clients. The client with which clinical manifestation
requires immediate attention from the nurse?
A. Respiratory rate of 25 breaths per minute after resting for 3 minutes after activity
B. Blood pressure of 140/90 mmHg
C. Heart rate of 88 beats per minute
D. Temperature of 99.2°F (37.3°C)
Correct Answer: A
Rationale: A respiratory rate of 25 breaths per minute is tachypneic and indicates
respiratory distress, especially after a 3-minute rest period following activity. The normal
adult respiratory rate is 12–20 breaths per minute. Elevated respiratory rate can signal
hypoxia, pain, anxiety, or impending respiratory failure and requires immediate nursing
assessment and intervention. Options B, C, and D represent values that are either
mildly elevated or within normal range and do not constitute an immediate priority.
2. The nurse places a client who had abdominal surgery in the semi-Fowler
position. The client states, "I prefer to lie flat when in bed. I feel like I am almost
sitting up." Which is an appropriate response by the nurse?
A. "Lying flat will increase your risk of developing a pulmonary embolism."
B. "Lifting your chest above your abdomen facilitates drainage in your wound."
C. "The semi-Fowler position is required for all postoperative abdominal clients."
D. "You can lie flat, but you must change positions every 15 minutes."
Correct Answer: B
,Rationale: The semi-Fowler position (head of bed elevated 30–45 degrees) is indicated
after abdominal surgery because it reduces tension on the incision, promotes wound
drainage, decreases intra-abdominal pressure, and facilitates respiratory expansion.
This response provides a clear, physiologically sound explanation that addresses the
client's concern while reinforcing the therapeutic benefit. Option A is fear-inducing and
not the primary rationale; Option C is authoritarian without explanation; Option D is
impractical and not evidence-based.
3. The nurse is educating a client who has just been prescribed a diuretic about
how to safely perform activities of daily living. Which statement should the nurse
include in the teaching?
A. "Take your diuretic at bedtime to avoid daytime urinary frequency."
B. "Change positions slowly to minimize orthostatic hypotension."
C. "Increase your sodium intake to replace what is lost in urine."
D. "Weigh yourself once weekly to monitor for weight gain."
Correct Answer: B
Rationale: Diuretics promote fluid loss, which can lead to volume depletion and
orthostatic hypotension—a drop in blood pressure upon standing that causes dizziness
and increases fall risk. Teaching the client to change positions slowly (supine → sitting
→ standing) allows the cardiovascular system time to compensate and prevents
syncope. Option A is incorrect because diuretics should be taken in the morning to
prevent nocturia; Option C is contraindicated as diuretics are often prescribed to reduce
sodium-related fluid retention; Option D is incorrect because clients should weigh
themselves daily, not weekly, to monitor for fluid retention or excessive loss.
4. The nurse recognizes that which statements made by a patient indicate an
understanding of behaviors that will promote sleep? (Select all that apply.)
A. "I will not watch television in bed."
B. "I will not drink caffeine later in the day."
C. "I will start to exercise regularly during the day."
D. "I will take a long nap every afternoon."
E. "I will keep my bedroom warm and brightly lit."
Correct Answers: A, B, C
Rationale: Sleep hygiene principles include: (A) avoiding stimulating activities such as
watching television in bed, which associates the bed with wakefulness rather than
,sleep; (B) avoiding caffeine (a stimulant) in the late afternoon or evening, as it has a
half-life of 3–5 hours and disrupts sleep onset; and (C) engaging in regular daytime
exercise, which promotes deeper sleep stages, provided it is not performed within 2–3
hours of bedtime. Option D is incorrect because long afternoon naps reduce sleep drive
and can cause sleep fragmentation at night. Option E is incorrect because a cool, dark
environment promotes melatonin secretion and optimal sleep quality.
5. Your patient is being discharged home and will be required to self-administer
injectable Heparin. You are observing the patient administer their scheduled dose
of Heparin to confirm that the patient knows how to do it correctly. What action by
the patient requires you to re-educate them about how to administer Heparin?
A. The patient cleanses the injection site with an alcohol swab and allows it to dry.
B. The patient injects the needle at a 90-degree angle into abdominal subcutaneous
tissue.
C. The patient injects the needle 1 inch away from the umbilicus.
D. The patient does not aspirate before injecting the medication.
Correct Answer: C
Rationale: Subcutaneous heparin should be administered in the abdominal fat layer at
least 2 inches (5 cm) away from the umbilicus to avoid vascular structures, ensure
proper absorption, and reduce the risk of bruising or hematoma. A 1-inch distance is
insufficient and places the patient at risk for complications. Option A is correct
technique; Option B is correct as heparin is given subcutaneously at 90 degrees in
patients with adequate abdominal adipose tissue; Option D is correct because
aspiration is not recommended for subcutaneous heparin administration as it may
increase bleeding risk and is unnecessary for this route.
6. A nurse caring for patients in a long-term care facility is often required to
collect urine specimens from patients for laboratory testing. Which techniques
for urine collection are performed correctly? (Select all that apply.)
A. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for
a urine culture.
B. The nurse discards the first urine of the day when performing a 24-hour urine
specimen collection on a patient.
C. The nurse obtains a clean-catch midstream specimen by cleaning the perineal area
from back to front.
D. The nurse clamps the indwelling catheter tubing for 15–30 minutes before obtaining
,Rationale:
The client’s heart rate has increased to 118 bpm, which may indicate worsening pain,
anxiety, physiological stress, or another postoperative complication. The nurse should
reassess for pain sources beyond the surgical site, use nonpharmacologic pain
interventions such as guided imagery, support safe mobility as tolerated, and consult
the surgeon if pain or abnormal vital signs persist. Postoperative clients require close
monitoring for changes that may indicate complications.
52. 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.
NURSE'S NOTES: Noted the client's clothes and sheets are wet. The client voided
approximately 75 mL of urine. The client's sister says that he usually wears adult
diapers at home as he is unable to communicate when he needs to void.
Correct Answer:
Potential Condition:
Overflow urinary incontinence
Actions to Take:
• Provide skin care
• Place an incontinence containment product under the client
Parameters to Monitor:
• Intake and output
• Skin integrity
• Post-void residual
Rationale:
The client is unable to communicate the need to void and has wet clothing and linens
with only a small amount of urine output, which may indicate overflow urinary
incontinence. Overflow incontinence can occur when the bladder does not empty
completely, causing leakage. The nurse should protect the skin from moisture-related
breakdown, use appropriate containment products, monitor intake and output, assess
skin integrity, and evaluate post-void residual to determine bladder emptying.
,53. The emergency department (ED) is caring for a 9-month-old male client who
was brought to the ED for nasal congestion, cough, fever, and difficulty
breathing. The client and his sister both attend daycare daily while their parents
are at work. The sister has been acting a bit run down but has not a fever or
oxygen deficit. For each statement, click to indicate whether the statement is true
or false.
Correct Answers:
• Hand washing needs to be performed when exiting the client's room. False
• This client requires contact and droplet precautions. True
• A gown and gloves should be worn any time there is potential for contact with
secretions. True
• A mask should always be worn when in the client's room. True
• This client would require a private room if admitted. True
Rationale:
A 9-month-old with fever, cough, nasal congestion, and difficulty breathing is at risk for a
contagious respiratory infection. Contact and droplet precautions are appropriate to
reduce transmission through respiratory secretions and contaminated surfaces. Staff
should use appropriate personal protective equipment, including mask, gown, and
gloves when exposure to secretions is possible. A private room is preferred to reduce
spread to other vulnerable clients. Hand hygiene is required when entering and exiting
the room, not only when exiting.
54. The patient is a 36-year-old female who is in the clinic today for insomnia. She
reports that she started having trouble sleeping over a year ago after her father's
death. She has no medical problems and has never had surgery. She takes an
oral contraceptive and a multivitamin daily. She does not smoke but drinks one to
two glasses of wine every evening. What other recommendations could the nurse
give to help the patient have better sleep? Select all that apply.
Correct Answers:
• Avoid alcohol in the evening
• Try to go to bed and awaken at the same time every day
• Avoid naps
,26. When identifying the goals to be included in a client's plan of care, the nurse
should take which action?
A. Review the priority nursing problems included in the plan of care
B. Consult with the healthcare provider to establish all goals
C. Write goals that are vague to allow for flexibility in care
D. Focus exclusively on physiological goals before addressing psychosocial needs
Correct Answer: A
Rationale: Goals (outcomes) in a nursing care plan must directly address the identified
nursing diagnoses and be derived from the priority problems. The nurse reviews the
prioritized diagnoses to ensure goals are specific, measurable, achievable, relevant,
and time-bound (SMART). For example, if "impaired gas exchange" is the priority
diagnosis, the goal might be "SpO2 ≥92% on 2 L NC within 24 hours." Option B is
incorrect because nursing goals are within independent nursing scope; Option C
contradicts the requirement for measurable, specific outcomes; Option D ignores the
holistic nature of nursing care and Maslow's integrated hierarchy.
27. A female client with metastatic breast cancer is admitted with shortness of
breath and pleural effusions. The client has a living will and the family is
requesting hospice information. Which information should the nurse provide
regarding hospice? (Select all that apply.)
A. Hospice services can be initiated prior to discharge
B. Family members can be involved in the plan of care
C. Hospice provides comfort, dignity, and emotional support
D. Hospice can be provided within the comforts of home
E. Hospice requires the client to stop all current cancer treatments
Correct Answers: A, B, C, D
Rationale: (A) Hospice services can begin in the hospital and continue through
discharge to home or a hospice facility, ensuring seamless care transitions. (B) Hospice
philosophy emphasizes family-centered care, with family members participating in care
planning, symptom management education, and bereavement support. (C) The hospice
mission focuses on palliation of physical symptoms (pain, dyspnea) while preserving
dignity and providing psychosocial/spiritual support. (D) Most hospice care
(approximately 70%) is delivered in the patient's home, assisted living, or nursing home.
Option E is incorrect—while hospice typically focuses on comfort rather than curative
treatment, some hospice programs allow concurrent palliative chemotherapy or
,radiation for symptom control (the Medicare hospice benefit has been modified to allow
some concurrent care in certain situations).
28. The nurse observes a practical nurse (PN) performing oral care on an
unconscious client. Which action by the PN indicates to the nurse the need for
additional training?
A. Places the client in a supine position
B. Uses a soft toothbrush and oral swabs
C. Performs oral care every 2 hours
D. Applies water-based mouth moisturizer after cleaning
Correct Answer: A
Rationale: An unconscious client must never be placed in supine position for oral care
because the risk of aspiration is severe. The correct position is side-lying (lateral) with
the head turned toward the dependent side, or semi-Fowler's if tolerated, to allow saliva
and secretions to drain by gravity rather than pooling in the posterior pharynx. Options
B, C, and D represent evidence-based oral care for unconscious patients: soft tools
prevent mucosal injury; frequent care (every 2–4 hours) prevents ventilator-associated
pneumonia and maintains oral health; water-based moisturizers prevent xerostomia
without aspiration risk.
29. The nurse is preparing to give an emergency sedative injection to an agitated
client. Which action by the nurse comprises a tort?
A. Administering the medication without verifying the client's identity
B. Placing a client in restraints without having a healthcare provider's order
C. Failing to document the medication administration immediately
D. Not obtaining informed consent for the emergency medication
Correct Answer: B
Rationale: A tort is a civil wrong that causes harm or loss. Placing a client in restraints
without a healthcare provider's order constitutes false imprisonment (a type of
intentional tort) and battery if physical force is used. Restraints require a specific
physician or provider order, indication documentation, time limits, and frequent
reassessment per The Joint Commission and CMS regulations. Emergency chemical
sedation (Option A) requires verification but may proceed without traditional consent
under implied consent/emergency doctrine; Option C is a documentation error but not
, necessarily a tort; Option D is incorrect because emergency treatment can proceed
under implied consent when the patient lacks capacity and delay would cause harm.
30. The nurse observes an unlicensed assistive personnel (UAP) feeding a client
who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which
action by the UAP should the nurse recognize indicates the need for additional
teaching?
A. Positions the head with the chin tilted slightly downward
B. Places food on the unaffected side of the mouth
C. Allows the client to self-feed using the unaffected hand
D. Ensures the client is sitting upright at 90 degrees
Correct Answer: A
Rationale: The correct positioning for a dysphagic patient during feeding is the chin-
tuck or chin-down position (tucking the chin down toward the chest), NOT tilting the
chin downward toward the neck in a flexed position. The chin-tuck narrows the airway
entrance, widens the vallecular space, and delays laryngeal elevation, thereby
protecting the airway and facilitating swallowing. "Chin tilted slightly downward" as
described suggests a flexed neck position that actually increases aspiration risk by
altering oropharyngeal alignment. Options B, C, and D are correct techniques: placing
food on the unaffected side utilizes intact sensation and motor function; self-feeding
promotes independence and oral motor coordination; and 90-degree upright positioning
uses gravity to assist bolus transit.
31. It is most important for the nurse to recalculate the Braden scale score for a
client who has developed which problem?
A. Urinary incontinence
B. Mild anxiety about hospitalization
C. Decreased appetite with meals
D. Request for a different roommate
Correct Answer: A
Rationale: The Braden Scale for Predicting Pressure Sore Risk assesses six
subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Urinary incontinence directly impacts the moisture subscale, which evaluates the
degree to which skin is exposed to moisture. Incontinence increases moisture exposure,
causing maceration, raising the pH of the skin, and increasing friction—significantly
