WGU C239 ADVANCED TAX CONCEPTS
EXAMINATION QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
Set 1: Fundamentals of Nursing (Questions 1-50)
1. A nurse is preparing to administer a feeding via a nasogastric (NG) tube. Which
action should the nurse take first?
A) Flush the tube with 30 mL of water.
B) Check the placement of the tube.
C) Elevate the head of the bed to 45 degrees.
D) Aspirate residual gastric contents.
Correct Answer: B
Rationale: Patient safety is the priority. Checking placement (via X-ray or pH
testing) must be done first to prevent aspiration pneumonia. While elevating the
HOB and checking residuals are important, they are secondary to confirming
correct placement.
2. A client is on strict bed rest. Which intervention is most important to prevent deep
vein thrombosis (DVT)?
A) Apply sequential compression devices (SCDs).
B) Administer aspirin daily.
C) Perform passive range-of-motion exercises.
D) Increase oral fluid intake.
Correct Answer: A
,Rationale: SCDs are a mechanical prophylaxis that actively promote venous return
and prevent stasis. While fluids and ROM help, SCDs are the most direct
preventative measure for a bedridden patient.
3. The nurse is caring for a client with a stage III pressure ulcer. Which finding
indicates wound healing?
A) Deep tunneling with purulent drainage.
B) Dark brown eschar covering the wound.
C) Red beefy granulation tissue in the base.
D) Yellow slough tissue surrounding the edges.
Correct Answer: C
Rationale: Granulation tissue (red, moist, beefy) indicates new capillary growth and
active healing. Eschar (black/brown) and slough (yellow) are necrotic and must be
debrided before healing can occur.
4. A client refuses to take their prescribed medication. What is the nurse's best
response?
A) "You must take this medication to get better."
B) "I will have the doctor come talk to you."
C) "Can you tell me why you are refusing the medication?"
D) "I will put it aside for now and come back later."
Correct Answer: C
Rationale: The nurse should assess the reason for refusal (therapeutic
communication). This respects autonomy and allows the nurse to address concerns
(side effects, cost, etc.).
5. Which diet is appropriate for a client with celiac disease?
A) Low-sodium diet.
B) Gluten-free diet.
,C) High-fiber diet.
D) Low-fat diet.
Correct Answer: B
Rationale: Celiac disease is an autoimmune reaction to gluten (found in wheat,
barley, rye). A strict gluten-free diet is the only treatment.
6. A nurse uses a gait belt to assist a client with ambulation. Where should the gait
belt be placed?
A) Around the client's chest.
B) Around the client's waist.
C) Around the client's hips.
D) Around the client's thighs.
Correct Answer: B
Rationale: The gait belt should be snugly fitted around the client's waist (over
clothing) to provide a secure grip for the nurse without restricting breathing.
7. A client is diagnosed with a urinary tract infection (UTI). Which vital sign is most
indicative of a systemic infection?
A) Heart rate of 80 bpm.
B) Blood pressure of 110/70 mmHg.
C) Temperature of 101.5°F (38.6°C).
D) Respiratory rate of 16 breaths/min.
Correct Answer: C
Rationale: Fever is a classic sign of systemic infection. The other vitals listed are
within normal limits.
8. The nurse is performing hand hygiene. Which is the minimal amount of time the
nurse should rub hands together when using an alcohol-based hand rub?
, A) 5 seconds.
B) 15 seconds.
C) 30 seconds.
D) 60 seconds.
Correct Answer: B
Rationale: According to CDC guidelines, hands should be rubbed together for at
least 15-20 seconds until the solution dries.
9. A client has an order for "NPO" status. What does this mean?
A) Nothing by mouth.
B) Clear liquids only.
C) Full liquids only.
D) Soft foods only.
Correct Answer: A
Rationale: NPO is Latin for *nil per os*, meaning nothing by mouth (including water,
ice chips, and food).
10. Which is the safest position for a client who is experiencing a seizure?
A) Prone.
B) Supine.
C) Side-lying.
D) Trendelenburg.
Correct Answer: C
Rationale: The side-lying (or recovery) position helps keep the airway patent by
allowing saliva or vomitus to drain out of the mouth, preventing aspiration.
11. A client has an indwelling urinary catheter. To prevent infection, the nurse should
ensure the collection bag is:
EXAMINATION QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
Set 1: Fundamentals of Nursing (Questions 1-50)
1. A nurse is preparing to administer a feeding via a nasogastric (NG) tube. Which
action should the nurse take first?
A) Flush the tube with 30 mL of water.
B) Check the placement of the tube.
C) Elevate the head of the bed to 45 degrees.
D) Aspirate residual gastric contents.
Correct Answer: B
Rationale: Patient safety is the priority. Checking placement (via X-ray or pH
testing) must be done first to prevent aspiration pneumonia. While elevating the
HOB and checking residuals are important, they are secondary to confirming
correct placement.
2. A client is on strict bed rest. Which intervention is most important to prevent deep
vein thrombosis (DVT)?
A) Apply sequential compression devices (SCDs).
B) Administer aspirin daily.
C) Perform passive range-of-motion exercises.
D) Increase oral fluid intake.
Correct Answer: A
,Rationale: SCDs are a mechanical prophylaxis that actively promote venous return
and prevent stasis. While fluids and ROM help, SCDs are the most direct
preventative measure for a bedridden patient.
3. The nurse is caring for a client with a stage III pressure ulcer. Which finding
indicates wound healing?
A) Deep tunneling with purulent drainage.
B) Dark brown eschar covering the wound.
C) Red beefy granulation tissue in the base.
D) Yellow slough tissue surrounding the edges.
Correct Answer: C
Rationale: Granulation tissue (red, moist, beefy) indicates new capillary growth and
active healing. Eschar (black/brown) and slough (yellow) are necrotic and must be
debrided before healing can occur.
4. A client refuses to take their prescribed medication. What is the nurse's best
response?
A) "You must take this medication to get better."
B) "I will have the doctor come talk to you."
C) "Can you tell me why you are refusing the medication?"
D) "I will put it aside for now and come back later."
Correct Answer: C
Rationale: The nurse should assess the reason for refusal (therapeutic
communication). This respects autonomy and allows the nurse to address concerns
(side effects, cost, etc.).
5. Which diet is appropriate for a client with celiac disease?
A) Low-sodium diet.
B) Gluten-free diet.
,C) High-fiber diet.
D) Low-fat diet.
Correct Answer: B
Rationale: Celiac disease is an autoimmune reaction to gluten (found in wheat,
barley, rye). A strict gluten-free diet is the only treatment.
6. A nurse uses a gait belt to assist a client with ambulation. Where should the gait
belt be placed?
A) Around the client's chest.
B) Around the client's waist.
C) Around the client's hips.
D) Around the client's thighs.
Correct Answer: B
Rationale: The gait belt should be snugly fitted around the client's waist (over
clothing) to provide a secure grip for the nurse without restricting breathing.
7. A client is diagnosed with a urinary tract infection (UTI). Which vital sign is most
indicative of a systemic infection?
A) Heart rate of 80 bpm.
B) Blood pressure of 110/70 mmHg.
C) Temperature of 101.5°F (38.6°C).
D) Respiratory rate of 16 breaths/min.
Correct Answer: C
Rationale: Fever is a classic sign of systemic infection. The other vitals listed are
within normal limits.
8. The nurse is performing hand hygiene. Which is the minimal amount of time the
nurse should rub hands together when using an alcohol-based hand rub?
, A) 5 seconds.
B) 15 seconds.
C) 30 seconds.
D) 60 seconds.
Correct Answer: B
Rationale: According to CDC guidelines, hands should be rubbed together for at
least 15-20 seconds until the solution dries.
9. A client has an order for "NPO" status. What does this mean?
A) Nothing by mouth.
B) Clear liquids only.
C) Full liquids only.
D) Soft foods only.
Correct Answer: A
Rationale: NPO is Latin for *nil per os*, meaning nothing by mouth (including water,
ice chips, and food).
10. Which is the safest position for a client who is experiencing a seizure?
A) Prone.
B) Supine.
C) Side-lying.
D) Trendelenburg.
Correct Answer: C
Rationale: The side-lying (or recovery) position helps keep the airway patent by
allowing saliva or vomitus to drain out of the mouth, preventing aspiration.
11. A client has an indwelling urinary catheter. To prevent infection, the nurse should
ensure the collection bag is:
