300 Exam 2
Foundations of Nursing - GCU
Actual Questions and Answers
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Multiple-Choice (A–D), For Some Questions.
Each Question Includes The Correct Answer
Foundations of Nursing at Grand Canyon University
The nurse receives the patient's most recent blood work results.
Which laboratory value is of greatest concern?
,Correct Answer:
Calcium of 15.5 mg/dL
Explanation:
Normal calcium range is 9 to 10.5 mg/dL; therefore, a value of 15.5mg/dL is
abnormally high and of concern.
Normal sodium: 136 to 145 mEq/L
Normal potassium: 3.5 to 5.0 mEq/L
Normal chloride: 98 to 106 mEq/L
The patient is an 80-year-old male who is visiting the clinic today for
a routine physical examination. The patient's skin turgor is fair, but
the patient reports fatigue, lightheadedness, and weakness. The
skin is warm and dry, pulse rate is 116 beats/min, and urinary
sodium level is slightly elevated. Which instruction should the nurse
provide?
Correct Answer:
Drink more water to prevent further dehydration.
Explanation:
Thirst sensation diminishes as you age, leading to inadequate fluid intake or
dehydration; the client should be encouraged to drink more water/fluids.
Suggest the client keeps a pitcher of water near to maintain adequate fluid
intake. Symptoms of dehydration in older adults include confusion,
weakness, lightheadedness, hot dry skin, furrowed tongue, and high urinary
sodium. Milk continues to be an important food for older woman and men,
who need adequate calcium to protect against osteoporosis; the patient's
problem is dehydration, not osteoporosis.
The nurse will anticipate which diagnostic examination for a patient
with black tarry stools?
Correct Answer:
Endoscopy
Explanation:
, Black tarry stools are an indication of bleeding in the GI tract; endoscopy
would allow visualization of the bleeding. No other option (ultrasound,
barium enema, and anorectal manometry) would allow GI visualization.
A patient requests the nurse's help to the bedside commode and
becomes frustrated when unable to void in front of the nurse. How
should the nurse interpret the patient's inability to void?
Correct Answer:
The patient may be anxious, making it difficult for abdominal and perineal
muscles to relax enough to void.
Explanation:
Attempting to void in the presence of another can cause anxiety and tension
in the muscles that make voiding difficult. Anxiety can impact bladder
emptying due to inadequate relaxation of the pelvic floor muscles and
urinary sphincter. The nurse should give the patient privacy and adequate
time if appropriate. No evidence suggests that an underlying physiological
(does not recognize signals or not drinking enough fluids) or psychological
(lonely) condition exists.
While receiving a shift report on a female patient, the nurse is
informed that the patient has been experiencing urinary
incontinence. Upon assessment, which finding will the nurse expect?
Correct Answer:
Reddened irritated skin on buttocks
Explanation:
Urinary incontinence is uncontrolled urinary elimination; if the urine has
prolonged contact with the skin, skin breakdown can occur. If
this is a new occurrence, it is important for the nurse to investigate reasons
for the incontinence. An indwelling Foley catheter is a solution for urine
retention. Blood clots and foul-smelling discharge are often signs of infection.
In providing diet education for a patient on a low-fat diet, which
information is important for the nurse to share?
Correct Answer:
Saturated fats are found mostly in animal sources.