WGU D439 NURS 1011 Foundations of Nursing – Bachelor
of Science in Nursing Prelicensure (Pre-Nursing) Study
Guide, Original Practice Questions & Answers, Assessment
Preparation, Comprehensive Nursing Foundations Review,
Patient-Centered Care, Nursing Process, Safety, Infection
Prevention, Communication, Professional Nursing Roles &
Clinical Fundamentals
Question 1: A patient with diabetes insipidus is receiving desmopressin
acetate (DDAVP). Which assessment finding indicates a therapeutic response
to this medication?
A. Decreased serum sodium level
B. Increased urine output
C. Decreased urine specific gravity
D. Decreased thirst and nocturia
CORRECT ANSWER: D. Decreased thirst and nocturia
Rationale: Desmopressin is a synthetic analog of antidiuretic hormone (ADH) that acts
on the V2 receptors in the renal collecting ducts to promote water reabsorption. A
therapeutic response is demonstrated by reduced urinary output, decreased thirst, and a
resolution of nocturia. While serum sodium may correct, it is not the primary
therapeutic indicator; an increase in urine output or a decrease in specific gravity would
indicate treatment failure.
Question 2: A client is prescribed furosemide (Lasix) for the management of
heart failure. The nurse should instruct the client to report which symptom
immediately as a potential adverse effect?
A. Constipation
B. Tinnitus
C. Photosensitivity
D. Dry skin
CORRECT ANSWER: B. Tinnitus
Rationale: Furosemide is a loop diuretic that can cause ototoxicity, leading to tinnitus or
hearing loss. This is often dose-related and more common in patients with renal
impairment. Constipation, photosensitivity, and dry skin are not typical or emergent
adverse effects associated with furosemide.
Question 3: A nurse is performing an admission assessment on a patient with
suspected tuberculosis. Which finding is most characteristic of active
pulmonary tuberculosis?
A. Sudden onset of high fever with productive green sputum
B. Night sweats, weight loss, and hemoptysis
,C. Productive cough with yellow sputum and pleuritic chest pain
D. Dry, hacking cough with clear sputum
CORRECT ANSWER: B. Night sweats, weight loss, and hemoptysis
Rationale: Active pulmonary tuberculosis typically presents with a gradual onset of
systemic symptoms including night sweats, fever, weight loss, and fatigue. Pulmonary
symptoms include a productive cough and hemoptysis. Sudden onset high fever is more
characteristic of pneumonia. The presence of hemoptysis is a key distinguishing factor
from typical bacterial pneumonia.
Question 4: A patient is diagnosed with hyperkalemia. Which dietary
instruction is most appropriate for the nurse to provide?
A. Increase intake of bananas and oranges
B. Decrease intake of potatoes and tomatoes
C. Increase intake of salt substitutes
D. Decrease intake of dairy products
CORRECT ANSWER: B. Decrease intake of potatoes and tomatoes
Rationale: Dietary management of hyperkalemia involves restricting foods high in
potassium. Bananas, oranges, potatoes, tomatoes, and salt substitutes are all high in
potassium. The patient should be instructed to avoid these foods. Dairy products are not
high in potassium relative to these other items.
Question 5: A patient is receiving total parenteral nutrition (TPN) through a
central venous catheter. Which complication is most important for the nurse to
monitor for immediately?
A. Hyperglycemia
B. Catheter-related sepsis
C. Rebound hypoglycemia
D. Fluid volume overload
CORRECT ANSWER: B. Catheter-related sepsis
Rationale: While all options are potential complications of TPN, catheter-related sepsis
is the most serious and immediate threat due to the direct access to the central
circulation. Hyperglycemia is common but manageable. Rebound hypoglycemia occurs
upon abrupt discontinuation. Fluid overload is a risk but sepsis carries the highest
mortality risk.
Question 6: The nurse is caring for a patient with Cushing's syndrome. Which
clinical manifestation is consistent with this disorder?
,A. Bronze pigmentation of the skin
B. Hypoglycemia
C. Truncal obesity and buffalo hump
D. Hyperkalemia
CORRECT ANSWER: C. Truncal obesity and buffalo hump
Rationale: Cushing's syndrome results from chronic exposure to excess glucocorticoids.
Characteristic manifestations include central obesity (truncal obesity), a buffalo hump
(fat deposition in the cervical-dorsal area), moon face, and purple striae. Bronze
pigmentation is associated with Addison's disease. Hypoglycemia and hyperkalemia are
not classic findings.
Question 7: A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at 2 L/min via nasal cannula. Which assessment
finding indicates a potential complication of oxygen administration?
A. Increased respiratory rate
B. Drowsiness and confusion
C. Productive cough
D. Peripheral edema
CORRECT ANSWER: B. Drowsiness and confusion
Rationale: In patients with severe COPD, oxygen administration can lead to
hypoventilation due to loss of the hypoxic drive. Drowsiness, confusion, and a decreased
respiratory rate are signs of carbon dioxide retention (CO2 narcosis). An increased
respiratory rate would not indicate this complication.
Question 8: A nurse is preparing to administer heparin subcutaneously. Which
technique is correct for this administration?
A. Aspirate for blood return before injecting
B. Massage the site vigorously after injection
C. Inject into the abdominal fat with the needle at a 90-degree angle
D. Administer in the deltoid muscle
CORRECT ANSWER: C. Inject into the abdominal fat with the needle at a 90-
degree angle
Rationale: Subcutaneous heparin should be injected into the abdominal fat pad to
ensure absorption. The needle is inserted at a 90-degree angle. Do not aspirate or
massage the site; aspiration can cause bleeding and massage can increase bruising and
absorption rate. Intramuscular injections (deltoid) are not appropriate.
, Question 9: A patient is prescribed a low-sodium diet. Which food choice by
the patient indicates an understanding of the dietary teaching?
A. Canned vegetable soup
B. A sandwich with pickles and cheese
C. Grilled chicken with fresh vegetables
D. Soy sauce with steamed rice
CORRECT ANSWER: C. Grilled chicken with fresh vegetables
Rationale: A low-sodium diet restricts processed and canned foods. Fresh vegetables
and unprocessed meats like grilled chicken are low in sodium. Canned soup, pickles,
cheese, and soy sauce are all very high in sodium.
Question 10: The nurse is assessing a patient with right-sided heart failure.
Which finding is most characteristic of this condition?
A. Pulmonary crackles
B. Orthopnea
C. Jugular vein distention (JVD)
D. Productive cough with pink sputum
CORRECT ANSWER: C. Jugular vein distention (JVD)
Rationale: Right-sided heart failure leads to systemic venous congestion. This results in
peripheral edema, JVD, hepatomegaly, and ascites. Pulmonary congestion (crackles,
orthopnea, pink sputum) is associated with left-sided heart failure.
Question 11: A patient is admitted with acute pancreatitis. Which laboratory
value is most indicative of this condition?
A. Elevated serum amylase and lipase
B. Decreased serum glucose
C. Elevated serum potassium
D. Decreased serum calcium
CORRECT ANSWER: A. Elevated serum amylase and lipase
Rationale: Acute pancreatitis is characterized by a significant elevation in serum amylase
and lipase. Lipase is considered more specific to the pancreas. Hypocalcemia may occur
but is not diagnostic. Elevations in glucose are common, not decreases.
Question 12: The nurse is providing discharge teaching to a patient with a new
colostomy. Which statement indicates that the patient understands the care of
the stoma?
of Science in Nursing Prelicensure (Pre-Nursing) Study
Guide, Original Practice Questions & Answers, Assessment
Preparation, Comprehensive Nursing Foundations Review,
Patient-Centered Care, Nursing Process, Safety, Infection
Prevention, Communication, Professional Nursing Roles &
Clinical Fundamentals
Question 1: A patient with diabetes insipidus is receiving desmopressin
acetate (DDAVP). Which assessment finding indicates a therapeutic response
to this medication?
A. Decreased serum sodium level
B. Increased urine output
C. Decreased urine specific gravity
D. Decreased thirst and nocturia
CORRECT ANSWER: D. Decreased thirst and nocturia
Rationale: Desmopressin is a synthetic analog of antidiuretic hormone (ADH) that acts
on the V2 receptors in the renal collecting ducts to promote water reabsorption. A
therapeutic response is demonstrated by reduced urinary output, decreased thirst, and a
resolution of nocturia. While serum sodium may correct, it is not the primary
therapeutic indicator; an increase in urine output or a decrease in specific gravity would
indicate treatment failure.
Question 2: A client is prescribed furosemide (Lasix) for the management of
heart failure. The nurse should instruct the client to report which symptom
immediately as a potential adverse effect?
A. Constipation
B. Tinnitus
C. Photosensitivity
D. Dry skin
CORRECT ANSWER: B. Tinnitus
Rationale: Furosemide is a loop diuretic that can cause ototoxicity, leading to tinnitus or
hearing loss. This is often dose-related and more common in patients with renal
impairment. Constipation, photosensitivity, and dry skin are not typical or emergent
adverse effects associated with furosemide.
Question 3: A nurse is performing an admission assessment on a patient with
suspected tuberculosis. Which finding is most characteristic of active
pulmonary tuberculosis?
A. Sudden onset of high fever with productive green sputum
B. Night sweats, weight loss, and hemoptysis
,C. Productive cough with yellow sputum and pleuritic chest pain
D. Dry, hacking cough with clear sputum
CORRECT ANSWER: B. Night sweats, weight loss, and hemoptysis
Rationale: Active pulmonary tuberculosis typically presents with a gradual onset of
systemic symptoms including night sweats, fever, weight loss, and fatigue. Pulmonary
symptoms include a productive cough and hemoptysis. Sudden onset high fever is more
characteristic of pneumonia. The presence of hemoptysis is a key distinguishing factor
from typical bacterial pneumonia.
Question 4: A patient is diagnosed with hyperkalemia. Which dietary
instruction is most appropriate for the nurse to provide?
A. Increase intake of bananas and oranges
B. Decrease intake of potatoes and tomatoes
C. Increase intake of salt substitutes
D. Decrease intake of dairy products
CORRECT ANSWER: B. Decrease intake of potatoes and tomatoes
Rationale: Dietary management of hyperkalemia involves restricting foods high in
potassium. Bananas, oranges, potatoes, tomatoes, and salt substitutes are all high in
potassium. The patient should be instructed to avoid these foods. Dairy products are not
high in potassium relative to these other items.
Question 5: A patient is receiving total parenteral nutrition (TPN) through a
central venous catheter. Which complication is most important for the nurse to
monitor for immediately?
A. Hyperglycemia
B. Catheter-related sepsis
C. Rebound hypoglycemia
D. Fluid volume overload
CORRECT ANSWER: B. Catheter-related sepsis
Rationale: While all options are potential complications of TPN, catheter-related sepsis
is the most serious and immediate threat due to the direct access to the central
circulation. Hyperglycemia is common but manageable. Rebound hypoglycemia occurs
upon abrupt discontinuation. Fluid overload is a risk but sepsis carries the highest
mortality risk.
Question 6: The nurse is caring for a patient with Cushing's syndrome. Which
clinical manifestation is consistent with this disorder?
,A. Bronze pigmentation of the skin
B. Hypoglycemia
C. Truncal obesity and buffalo hump
D. Hyperkalemia
CORRECT ANSWER: C. Truncal obesity and buffalo hump
Rationale: Cushing's syndrome results from chronic exposure to excess glucocorticoids.
Characteristic manifestations include central obesity (truncal obesity), a buffalo hump
(fat deposition in the cervical-dorsal area), moon face, and purple striae. Bronze
pigmentation is associated with Addison's disease. Hypoglycemia and hyperkalemia are
not classic findings.
Question 7: A patient with chronic obstructive pulmonary disease (COPD) is
receiving oxygen therapy at 2 L/min via nasal cannula. Which assessment
finding indicates a potential complication of oxygen administration?
A. Increased respiratory rate
B. Drowsiness and confusion
C. Productive cough
D. Peripheral edema
CORRECT ANSWER: B. Drowsiness and confusion
Rationale: In patients with severe COPD, oxygen administration can lead to
hypoventilation due to loss of the hypoxic drive. Drowsiness, confusion, and a decreased
respiratory rate are signs of carbon dioxide retention (CO2 narcosis). An increased
respiratory rate would not indicate this complication.
Question 8: A nurse is preparing to administer heparin subcutaneously. Which
technique is correct for this administration?
A. Aspirate for blood return before injecting
B. Massage the site vigorously after injection
C. Inject into the abdominal fat with the needle at a 90-degree angle
D. Administer in the deltoid muscle
CORRECT ANSWER: C. Inject into the abdominal fat with the needle at a 90-
degree angle
Rationale: Subcutaneous heparin should be injected into the abdominal fat pad to
ensure absorption. The needle is inserted at a 90-degree angle. Do not aspirate or
massage the site; aspiration can cause bleeding and massage can increase bruising and
absorption rate. Intramuscular injections (deltoid) are not appropriate.
, Question 9: A patient is prescribed a low-sodium diet. Which food choice by
the patient indicates an understanding of the dietary teaching?
A. Canned vegetable soup
B. A sandwich with pickles and cheese
C. Grilled chicken with fresh vegetables
D. Soy sauce with steamed rice
CORRECT ANSWER: C. Grilled chicken with fresh vegetables
Rationale: A low-sodium diet restricts processed and canned foods. Fresh vegetables
and unprocessed meats like grilled chicken are low in sodium. Canned soup, pickles,
cheese, and soy sauce are all very high in sodium.
Question 10: The nurse is assessing a patient with right-sided heart failure.
Which finding is most characteristic of this condition?
A. Pulmonary crackles
B. Orthopnea
C. Jugular vein distention (JVD)
D. Productive cough with pink sputum
CORRECT ANSWER: C. Jugular vein distention (JVD)
Rationale: Right-sided heart failure leads to systemic venous congestion. This results in
peripheral edema, JVD, hepatomegaly, and ascites. Pulmonary congestion (crackles,
orthopnea, pink sputum) is associated with left-sided heart failure.
Question 11: A patient is admitted with acute pancreatitis. Which laboratory
value is most indicative of this condition?
A. Elevated serum amylase and lipase
B. Decreased serum glucose
C. Elevated serum potassium
D. Decreased serum calcium
CORRECT ANSWER: A. Elevated serum amylase and lipase
Rationale: Acute pancreatitis is characterized by a significant elevation in serum amylase
and lipase. Lipase is considered more specific to the pancreas. Hypocalcemia may occur
but is not diagnostic. Elevations in glucose are common, not decreases.
Question 12: The nurse is providing discharge teaching to a patient with a new
colostomy. Which statement indicates that the patient understands the care of
the stoma?
