WGU D445 INTERMEDIATE NURSING SKILLS
PRE-ASSESSMENT- SOLVED
1. A nurse is preparing to administer packed red blood cells (PRBCs). Which action
is most important immediately before starting the transfusion?
A. Obtain the patient's weight
B. Verify the blood product with another licensed nurse according to facility policy
C. Administer acetaminophen routinely
D. Flush the IV with dextrose 5% in water
2. Which IV solution is compatible with blood products for administration through
the same line?
A. Lactated Ringer's
B. Dextrose 5% in water
C. 0.9% sodium chloride
D. 0.45% sodium chloride
3. A patient develops chills, fever, and low back pain shortly after a blood
transfusion begins. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer an antipyretic
D. Increase the IV rate
4. A nurse is assessing a peripheral IV site. Which finding requires immediate
intervention?
A. Mild bruising near the insertion site
B. Transparent dressing intact
C. Coolness, swelling, and pallor around the site
D. IV tubing secured with tape
5. Which finding is most consistent with IV infiltration?
A. Redness and warmth along the vein
B. Swelling and coolness around the catheter
C. Purulent drainage
D. Palpable venous cord
6. Which finding most strongly suggests phlebitis at a peripheral IV site?
A. Cool, pale skin
,B. Edema without redness
C. Warmth, redness, and tenderness along the vein
D. Absence of blood return
7. A patient has a tracheostomy and suddenly develops respiratory distress. Which
nursing action has the highest priority?
A. Offer oral fluids
B. Assess airway patency
C. Place the patient flat
D. Remove the tracheostomy ties
8. Which assessment finding indicates a patient may need airway suctioning?
A. Clear breath sounds
B. Strong productive cough
C. Coarse or gurgling breath sounds with visible secretions
D. Respiratory rate of 16/minute
9. During tracheostomy suctioning, the nurse should:
A. Apply suction while inserting the catheter
B. Apply suction while withdrawing the catheter
C. Suction continuously for 30 seconds
D. Instill sterile water routinely before every suction pass
10. A patient receiving oxygen through a nasal cannula reports dryness of the nasal
passages. Which intervention is appropriate?
A. Apply petroleum jelly inside the nares
B. Increase oxygen flow without an order
C. Use an appropriate water-soluble lubricant
D. Discontinue oxygen
11. Which patient should the nurse assess first?
A. Patient with a healing surgical incision
B. Patient requesting assistance with bathing
C. Patient with new-onset stridor
D. Patient reporting mild incisional pain
12. What is the primary purpose of incentive spirometry after surgery?
A. Prevent urinary retention
B. Promote lung expansion and prevent atelectasis
C. Reduce blood pressure
D. Increase gastrointestinal motility
, 13. A postoperative patient refuses to ambulate because of incisional pain. What
should the nurse do first?
A. Tell the patient ambulation is mandatory
B. Assess the patient's pain and provide appropriate pain management
C. Keep the patient on bed rest
D. Ask the provider to discontinue ambulation orders
14. Which postoperative finding requires the most immediate intervention?
A. Incisional discomfort rated 3/10
B. Temperature of 37.4°C (99.3°F)
C. Oxygen saturation of 86%
D. Mild fatigue
15. Which wound finding is most concerning for infection?
A. Pink granulation tissue
B. Small amount of serous drainage
C. Purulent drainage with increasing redness
D. Mild tenderness immediately after surgery
16. A patient with a pressure injury has nonblanchable erythema over intact skin.
How should the nurse classify this finding?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Unstageable pressure injury
17. Which intervention is most appropriate for preventing pressure injuries in an
immobile patient?
A. Massage reddened bony prominences
B. Reposition the patient regularly
C. Keep the patient's skin continuously moist
D. Use donut-shaped devices under all bony prominences
18. Which characteristic describes healthy granulation tissue?
A. Black and necrotic
B. Yellow and purulent
C. Pink or red and moist
D. Dry and hard
19. A postoperative wound suddenly separates and abdominal organs are visible.
PRE-ASSESSMENT- SOLVED
1. A nurse is preparing to administer packed red blood cells (PRBCs). Which action
is most important immediately before starting the transfusion?
A. Obtain the patient's weight
B. Verify the blood product with another licensed nurse according to facility policy
C. Administer acetaminophen routinely
D. Flush the IV with dextrose 5% in water
2. Which IV solution is compatible with blood products for administration through
the same line?
A. Lactated Ringer's
B. Dextrose 5% in water
C. 0.9% sodium chloride
D. 0.45% sodium chloride
3. A patient develops chills, fever, and low back pain shortly after a blood
transfusion begins. What should the nurse do first?
A. Slow the transfusion
B. Stop the transfusion
C. Administer an antipyretic
D. Increase the IV rate
4. A nurse is assessing a peripheral IV site. Which finding requires immediate
intervention?
A. Mild bruising near the insertion site
B. Transparent dressing intact
C. Coolness, swelling, and pallor around the site
D. IV tubing secured with tape
5. Which finding is most consistent with IV infiltration?
A. Redness and warmth along the vein
B. Swelling and coolness around the catheter
C. Purulent drainage
D. Palpable venous cord
6. Which finding most strongly suggests phlebitis at a peripheral IV site?
A. Cool, pale skin
,B. Edema without redness
C. Warmth, redness, and tenderness along the vein
D. Absence of blood return
7. A patient has a tracheostomy and suddenly develops respiratory distress. Which
nursing action has the highest priority?
A. Offer oral fluids
B. Assess airway patency
C. Place the patient flat
D. Remove the tracheostomy ties
8. Which assessment finding indicates a patient may need airway suctioning?
A. Clear breath sounds
B. Strong productive cough
C. Coarse or gurgling breath sounds with visible secretions
D. Respiratory rate of 16/minute
9. During tracheostomy suctioning, the nurse should:
A. Apply suction while inserting the catheter
B. Apply suction while withdrawing the catheter
C. Suction continuously for 30 seconds
D. Instill sterile water routinely before every suction pass
10. A patient receiving oxygen through a nasal cannula reports dryness of the nasal
passages. Which intervention is appropriate?
A. Apply petroleum jelly inside the nares
B. Increase oxygen flow without an order
C. Use an appropriate water-soluble lubricant
D. Discontinue oxygen
11. Which patient should the nurse assess first?
A. Patient with a healing surgical incision
B. Patient requesting assistance with bathing
C. Patient with new-onset stridor
D. Patient reporting mild incisional pain
12. What is the primary purpose of incentive spirometry after surgery?
A. Prevent urinary retention
B. Promote lung expansion and prevent atelectasis
C. Reduce blood pressure
D. Increase gastrointestinal motility
, 13. A postoperative patient refuses to ambulate because of incisional pain. What
should the nurse do first?
A. Tell the patient ambulation is mandatory
B. Assess the patient's pain and provide appropriate pain management
C. Keep the patient on bed rest
D. Ask the provider to discontinue ambulation orders
14. Which postoperative finding requires the most immediate intervention?
A. Incisional discomfort rated 3/10
B. Temperature of 37.4°C (99.3°F)
C. Oxygen saturation of 86%
D. Mild fatigue
15. Which wound finding is most concerning for infection?
A. Pink granulation tissue
B. Small amount of serous drainage
C. Purulent drainage with increasing redness
D. Mild tenderness immediately after surgery
16. A patient with a pressure injury has nonblanchable erythema over intact skin.
How should the nurse classify this finding?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Unstageable pressure injury
17. Which intervention is most appropriate for preventing pressure injuries in an
immobile patient?
A. Massage reddened bony prominences
B. Reposition the patient regularly
C. Keep the patient's skin continuously moist
D. Use donut-shaped devices under all bony prominences
18. Which characteristic describes healthy granulation tissue?
A. Black and necrotic
B. Yellow and purulent
C. Pink or red and moist
D. Dry and hard
19. A postoperative wound suddenly separates and abdominal organs are visible.
