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, Nursing Concepts,
Patient Care, Safety, Clinical Fundamentals,
Professional Nursing Practice, Communication &
Nursing Process
Question 1: A client who is 2 days post-operative following an abdominal
hysterectomy reports a sudden onset of chest pain and shortness of breath.
The nurse notes a heart rate of 110 bpm and respiratory rate of 28
breaths/min. Which action should the nurse take first?
A. Administer prescribed PRN morphine sulfate for pain.
B. Apply oxygen via nasal cannula at 2-4 L/min.
C. Perform a 12-lead electrocardiogram.
D. Notify the healthcare provider immediately.
CORRECT ANSWER: B. Apply oxygen via nasal cannula at 2-4 L/min.
Rationale: The client's symptoms are suggestive of a pulmonary embolism (PE). The
immediate priority is to address hypoxemia and improve oxygenation. Applying oxygen
is the first step in the emergency management of a suspected PE. While notifying the
provider and obtaining an ECG are important, they are secondary to stabilizing the
client's airway and breathing.
Question 2: A nurse is providing education to a client with a new diagnosis of
Type 1 Diabetes Mellitus. Which statement by the client indicates an
understanding of the peak action time of NPH insulin?
A. "I should eat a snack before my evening meal to prevent hypoglycemia."
B. "I will take my NPH insulin 30 minutes before breakfast and dinner."
C. "I need to be careful about hypoglycemia between 2 PM and 4 PM."
D. "This insulin will start working in about 15 minutes."
CORRECT ANSWER: C. "I need to be careful about hypoglycemia between 2
PM and 4 PM."
Rationale: NPH insulin (intermediate-acting) has an onset of 1-2 hours and a peak action
time of approximately 4-12 hours. If administered before breakfast, its peak would occur
in the afternoon (around 2-4 PM), increasing the risk of hypoglycemia at that time. The
client should understand the importance of monitoring blood glucose and eating a
snack during peak times.
,Question 3: A nurse is caring for a client with a chest tube connected to a
closed-chest drainage system. The nurse notices continuous bubbling in the
water seal chamber. What is the most appropriate initial nursing action?
A. Clamp the chest tube close to the insertion site.
B. Increase the suction level on the drainage system.
C. Assess the drainage system for an air leak.
D. Document the finding as normal function of the system.
CORRECT ANSWER: C. Assess the drainage system for an air leak.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. The first step is to assess the system and the chest tube insertion site to locate
the source of the leak. Clamping the tube should be avoided if possible, as it can cause a
tension pneumothorax. Intermittent bubbling is normal as it reflects air escaping from
the pleural space.
Question 4: In the context of psychiatric nursing, which ethical principle is
primarily being upheld when a nurse ensures a client is provided with all
necessary information, including risks and benefits, before they sign a consent
form?
A. Beneficence
B. Fidelity
C. Justice
D. Autonomy
CORRECT ANSWER: D. Autonomy
Rationale: Autonomy refers to the right of clients to make their own decisions regarding
their healthcare. By providing full disclosure of risks and benefits, the nurse empowers
the client to make an informed, voluntary decision, thereby upholding their autonomy.
Question 5: A nurse is preparing to administer an enteral feeding via a
nasogastric (NG) tube. Which action is essential to confirm correct placement
of the tube before starting the feeding?
A. Auscultate over the stomach while injecting air.
B. Check the pH of the gastric aspirate.
C. Place the end of the tube in water to observe for bubbles.
D. Measure the length of the exposed tubing.
CORRECT ANSWER: B. Check the pH of the gastric aspirate.
Rationale: The most reliable method to verify NG tube placement is to check the pH of
aspirated fluid. Gastric fluid typically has a pH of 5 or less. Auscultation (the "whoosh"
,test) is no longer considered a reliable method. Observing for bubbles or measuring
external length are not definitive for confirming placement.
Question 6: The nurse is caring for a client in the emergent phase of a burn
injury. Which assessment finding is the priority to report to the healthcare
provider?
A. Client reports a pain level of 8 out of 10.
B. Urine output is 20 mL over the last hour.
C. Heart rate is 102 beats per minute.
D. Client is experiencing shivering.
CORRECT ANSWER: B. Urine output is 20 mL over the last hour.
Rationale: In the emergent phase of burn injury, a primary goal is to maintain adequate
tissue perfusion and prevent hypovolemic shock. Urine output is a key indicator of
kidney perfusion. An output of less than 30 mL/hour indicates inadequate fluid
resuscitation and requires immediate intervention.
Question 7: A client with Major Depressive Disorder is prescribed phenelzine,
a monoamine oxidase inhibitor (MAOI). Which dietary instruction is most
critical for the nurse to provide?
A. "Limit your intake of foods high in tyramine."
B. "Avoid grapefruit juice while taking this medication."
C. "Increase your intake of leafy green vegetables."
D. "Ensure you are consuming a high-protein diet."
CORRECT ANSWER: A. "Limit your intake of foods high in tyramine."
Rationale: Phenelzine is an MAOI. Consumption of foods high in tyramine (e.g., aged
cheeses, cured meats, Chianti wine) can precipitate a hypertensive crisis, which is life-
threatening. This dietary restriction is the most critical education point for this
medication.
Question 8: A nurse is assessing a full-term newborn 1 hour after birth. Which
finding should be reported to the healthcare provider?
A. Heart rate of 140 beats per minute.
B. Respiratory rate of 38 breaths per minute with slight grunting.
C. Axillary temperature of 36.8°C (98.2°F).
D. Acrocyanosis of the hands and feet.
CORRECT ANSWER: B. Respiratory rate of 38 breaths per minute with slight
grunting.
, Rationale: While the respiratory rate is within normal range, the presence of grunting is
a sign of respiratory distress. Grunting is an attempt to maintain functional residual
capacity and is an abnormal finding requiring immediate further assessment. Heart rate
and temperature are normal, and acrocyanosis is a normal finding in the first few hours
of life.
Question 9: A client is diagnosed with Glomerulonephritis. Which assessment
finding is most consistent with this diagnosis?
A. Bilateral flank pain and high fever.
B. Cola-colored urine and periorbital edema.
C. Polyuria and polydipsia.
D. Frank hematuria and severe hypotension.
CORRECT ANSWER: B. Cola-colored urine and periorbital edema.
Rationale: Glomerulonephritis is characterized by inflammation of the glomeruli, leading
to hematuria (giving urine a cola or tea color), proteinuria, and sodium/water retention
resulting in periorbital and dependent edema. Flank pain and fever are more suggestive
of pyelonephritis.
Question 10: The nurse is evaluating a client who is 4 hours post-total hip
arthroplasty. Which intervention is most important to prevent postoperative
complications?
A. Maintaining the client in a low-Fowler's position.
B. Encouraging the client to perform ankle pumps every hour.
C. Keeping the client's hips adducted and internally rotated.
D. Administering pain medication only when the client requests it.
CORRECT ANSWER: B. Encouraging the client to perform ankle pumps every
hour.
Rationale: After hip arthroplasty, the client is at high risk for deep vein thrombosis (DVT)
due to decreased mobility and venous stasis. Ankle pumps promote venous return in the
lower extremities and are a crucial preventative measure. The hips should be abducted
and externally rotated, and pain medication should be administered on a scheduled
basis to facilitate mobility.
Question 11: A nurse is reviewing the laboratory results for a client taking
furosemide. Which result should be reported to the provider?
A. Serum potassium level of 3.2 mEq/L.
B. Serum sodium level of 140 mEq/L.
Bachelor of Science in Nursing Prelicensure (Pre-
Nursing) Study Guide, Original Practice Questions &
Answers, Assessment Preparation, Comprehensive
Nursing Foundations Review, Nursing Concepts,
Patient Care, Safety, Clinical Fundamentals,
Professional Nursing Practice, Communication &
Nursing Process
Question 1: A client who is 2 days post-operative following an abdominal
hysterectomy reports a sudden onset of chest pain and shortness of breath.
The nurse notes a heart rate of 110 bpm and respiratory rate of 28
breaths/min. Which action should the nurse take first?
A. Administer prescribed PRN morphine sulfate for pain.
B. Apply oxygen via nasal cannula at 2-4 L/min.
C. Perform a 12-lead electrocardiogram.
D. Notify the healthcare provider immediately.
CORRECT ANSWER: B. Apply oxygen via nasal cannula at 2-4 L/min.
Rationale: The client's symptoms are suggestive of a pulmonary embolism (PE). The
immediate priority is to address hypoxemia and improve oxygenation. Applying oxygen
is the first step in the emergency management of a suspected PE. While notifying the
provider and obtaining an ECG are important, they are secondary to stabilizing the
client's airway and breathing.
Question 2: A nurse is providing education to a client with a new diagnosis of
Type 1 Diabetes Mellitus. Which statement by the client indicates an
understanding of the peak action time of NPH insulin?
A. "I should eat a snack before my evening meal to prevent hypoglycemia."
B. "I will take my NPH insulin 30 minutes before breakfast and dinner."
C. "I need to be careful about hypoglycemia between 2 PM and 4 PM."
D. "This insulin will start working in about 15 minutes."
CORRECT ANSWER: C. "I need to be careful about hypoglycemia between 2
PM and 4 PM."
Rationale: NPH insulin (intermediate-acting) has an onset of 1-2 hours and a peak action
time of approximately 4-12 hours. If administered before breakfast, its peak would occur
in the afternoon (around 2-4 PM), increasing the risk of hypoglycemia at that time. The
client should understand the importance of monitoring blood glucose and eating a
snack during peak times.
,Question 3: A nurse is caring for a client with a chest tube connected to a
closed-chest drainage system. The nurse notices continuous bubbling in the
water seal chamber. What is the most appropriate initial nursing action?
A. Clamp the chest tube close to the insertion site.
B. Increase the suction level on the drainage system.
C. Assess the drainage system for an air leak.
D. Document the finding as normal function of the system.
CORRECT ANSWER: C. Assess the drainage system for an air leak.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the
system. The first step is to assess the system and the chest tube insertion site to locate
the source of the leak. Clamping the tube should be avoided if possible, as it can cause a
tension pneumothorax. Intermittent bubbling is normal as it reflects air escaping from
the pleural space.
Question 4: In the context of psychiatric nursing, which ethical principle is
primarily being upheld when a nurse ensures a client is provided with all
necessary information, including risks and benefits, before they sign a consent
form?
A. Beneficence
B. Fidelity
C. Justice
D. Autonomy
CORRECT ANSWER: D. Autonomy
Rationale: Autonomy refers to the right of clients to make their own decisions regarding
their healthcare. By providing full disclosure of risks and benefits, the nurse empowers
the client to make an informed, voluntary decision, thereby upholding their autonomy.
Question 5: A nurse is preparing to administer an enteral feeding via a
nasogastric (NG) tube. Which action is essential to confirm correct placement
of the tube before starting the feeding?
A. Auscultate over the stomach while injecting air.
B. Check the pH of the gastric aspirate.
C. Place the end of the tube in water to observe for bubbles.
D. Measure the length of the exposed tubing.
CORRECT ANSWER: B. Check the pH of the gastric aspirate.
Rationale: The most reliable method to verify NG tube placement is to check the pH of
aspirated fluid. Gastric fluid typically has a pH of 5 or less. Auscultation (the "whoosh"
,test) is no longer considered a reliable method. Observing for bubbles or measuring
external length are not definitive for confirming placement.
Question 6: The nurse is caring for a client in the emergent phase of a burn
injury. Which assessment finding is the priority to report to the healthcare
provider?
A. Client reports a pain level of 8 out of 10.
B. Urine output is 20 mL over the last hour.
C. Heart rate is 102 beats per minute.
D. Client is experiencing shivering.
CORRECT ANSWER: B. Urine output is 20 mL over the last hour.
Rationale: In the emergent phase of burn injury, a primary goal is to maintain adequate
tissue perfusion and prevent hypovolemic shock. Urine output is a key indicator of
kidney perfusion. An output of less than 30 mL/hour indicates inadequate fluid
resuscitation and requires immediate intervention.
Question 7: A client with Major Depressive Disorder is prescribed phenelzine,
a monoamine oxidase inhibitor (MAOI). Which dietary instruction is most
critical for the nurse to provide?
A. "Limit your intake of foods high in tyramine."
B. "Avoid grapefruit juice while taking this medication."
C. "Increase your intake of leafy green vegetables."
D. "Ensure you are consuming a high-protein diet."
CORRECT ANSWER: A. "Limit your intake of foods high in tyramine."
Rationale: Phenelzine is an MAOI. Consumption of foods high in tyramine (e.g., aged
cheeses, cured meats, Chianti wine) can precipitate a hypertensive crisis, which is life-
threatening. This dietary restriction is the most critical education point for this
medication.
Question 8: A nurse is assessing a full-term newborn 1 hour after birth. Which
finding should be reported to the healthcare provider?
A. Heart rate of 140 beats per minute.
B. Respiratory rate of 38 breaths per minute with slight grunting.
C. Axillary temperature of 36.8°C (98.2°F).
D. Acrocyanosis of the hands and feet.
CORRECT ANSWER: B. Respiratory rate of 38 breaths per minute with slight
grunting.
, Rationale: While the respiratory rate is within normal range, the presence of grunting is
a sign of respiratory distress. Grunting is an attempt to maintain functional residual
capacity and is an abnormal finding requiring immediate further assessment. Heart rate
and temperature are normal, and acrocyanosis is a normal finding in the first few hours
of life.
Question 9: A client is diagnosed with Glomerulonephritis. Which assessment
finding is most consistent with this diagnosis?
A. Bilateral flank pain and high fever.
B. Cola-colored urine and periorbital edema.
C. Polyuria and polydipsia.
D. Frank hematuria and severe hypotension.
CORRECT ANSWER: B. Cola-colored urine and periorbital edema.
Rationale: Glomerulonephritis is characterized by inflammation of the glomeruli, leading
to hematuria (giving urine a cola or tea color), proteinuria, and sodium/water retention
resulting in periorbital and dependent edema. Flank pain and fever are more suggestive
of pyelonephritis.
Question 10: The nurse is evaluating a client who is 4 hours post-total hip
arthroplasty. Which intervention is most important to prevent postoperative
complications?
A. Maintaining the client in a low-Fowler's position.
B. Encouraging the client to perform ankle pumps every hour.
C. Keeping the client's hips adducted and internally rotated.
D. Administering pain medication only when the client requests it.
CORRECT ANSWER: B. Encouraging the client to perform ankle pumps every
hour.
Rationale: After hip arthroplasty, the client is at high risk for deep vein thrombosis (DVT)
due to decreased mobility and venous stasis. Ankle pumps promote venous return in the
lower extremities and are a crucial preventative measure. The hips should be abducted
and externally rotated, and pain medication should be administered on a scheduled
basis to facilitate mobility.
Question 11: A nurse is reviewing the laboratory results for a client taking
furosemide. Which result should be reported to the provider?
A. Serum potassium level of 3.2 mEq/L.
B. Serum sodium level of 140 mEq/L.
