NSG 300 EXAM 2 FROM GRAND CANYON UNIVERSITY (GCU)
INCLUDES ACCURATE AND VERIFIED QUESTIONS COVERING
FOUNDATIONAL NURSING CONCEPTS SUCH AS THE NURSING
PROCESS, CRITICAL THINKING, PATIENT SAFETY,
COMMUNICATION, AND EVIDENCE BASED PRACTICE
The nurse reviewing laboratory blood results will expect to observe which cation in the most
abundance? - ANSWER-Correct Answer:
Sodium
Explanation:
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular
cation. Chloride is an anion (negatively charged) rather than a cation (positively charged).
Magnesium is found predominantly inside cells and in bone. Which of these electrolytes would
have the greatest affect on BP?
A client is on complete bowel rest. What will the nurse tell the client about his diet? - ANSWER-
Correct Answer:
You will be receiving total parenteral nutrition (TPN).
Explanation:
Complete bowel rest involves giving your digestive system a break from eating any food by
mouth. TPN allows bowel rest while supplying adequate calorific intake and essential nutrients,
and removes antigenic mucosal stimuli. The BRAT diet (Bananas, Rice, Applesauce, Toast) was
once a staple of most pediatricians' recommendations for children with an upset stomach. It is
generally no longer recommended. Increasing fluids is appropriate for clients with dehydration,
not complete bowel rest. Eating a variety of foods is generally recommended for all clients
unless there are medical contraindications.
1|Page
,The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation
related to opioid use. Which outcome will the nurse evaluate as successful for the patient to
establish normal defecation? - ANSWER-The patient reports eliminating a soft, formed stool.
Explanation:
The nurse's goal is for the patient to take opioid medication and to have normal bowel
elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired
outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does
not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not
an indication of defecation.
The patient diagnosed with cardiovascular disease is receiving dietary instructions from the
nurse. Which information from the patient indicates teaching is successful? - ANSWER-Correct
Answer:
Limit cholesterol to less than 300 mg/day.
Explanation:
American Heart Association guidelines recommend limiting cholesterol to less than 300 mg/day.
Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber
foods. Maintaining a prescribed carbohydrate intake is necessary for diabetes mellitus.
The patient has just started on enteral feedings, and is now reporting abdominal cramping.
Which action will the nurse take next? - ANSWER-Correct Answer:
Slow the rate of tube feeding.
Explanation:
One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the
rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the
use of cold formula. The nurse should warm the formula to room temperature. High-fat
formulas are also a cause of abdominal cramping.
2|Page
,The health care provider asks the nurse to monitor the fluid volume status of a heart failure
patient and a patient at risk for clinical dehydration. Which is the most effective nursing
intervention for monitoring both of these patients? - ANSWER-Correct Answer:
Weigh the patients every morning before breakfast
Explanation:
An effective measure of fluid retention or loss is daily weights; each kg (2.2 pounds) change is
equivalent to 1 L of fluid gained or lost. This measurement should be performed at the same
time every day using the same scale and the same amount of clothing. Although intake and
output records are important assessment measures, some patients are not able to keep their
own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit
but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs
with ECV excess but not with clinical dehydration.
A patient is experiencing oliguria. Which action should the nurse perform first? - ANSWER-
Correct Answer:
Assess for bladder distention.
Explanation:
Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all
assessment data to determine the potential cause of oliguria. It could be that the patient does
not have adequate intake, or it could be that the bladder sphincter is not functioning and the
patient is retaining water. Increasing fluids is effective if the patient does not have adequate
intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying
pathology is present. An order for diuretics can be obtained if the patient is retaining water, but
this should not be the first action.
Four patients arrive at the emergency department at the same time. Which patient will the
nurse see first? - ANSWER-Correct Answer:
An infant with temperature of 102.2° F and diarrhea for 3 days
3|Page
, Explanation:
The infant should be seen first. An infant's proportion of total body water (70% to 80% total
body weight) is greater than that of children or adults. Infants and young children have greater
water needs and immature kidneys. They are at greater risk for extracellular volume deficit and
hypernatremia because body water loss is proportionately greater per kilogram of weight. A
teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in
pain can wait as can an older adult with a blood pressure of 112/60.
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift
to occur in what direction? - ANSWER-Correct Answer:
From intracellular to extracellular
Explanation:
Hypertonic solutions (D5LR) will move fluid from the intracellular to the extracellular
(intravascular). A hypertonic solution has a concentration greater than normal body fluids, so
water will shift out of cells because of the osmotic pull of the extra particles. Movement of
water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids
(0.45%NS) are administered. Distribution of fluid between intravascular and interstitial spaces
occurs by filtration, the net sum of hydrostatic and osmotic pressures.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the
nurse take when feeding this patient? - ANSWER-Correct Answer:
Flex head with chin-down.
Explanation:
Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the
patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger
side of the mouth. Provide a 30-minute rest period before eating and position the patient in an
upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such
as water and fruit juice are difficult to control in the mouth and are more easily aspirated.
4|Page
INCLUDES ACCURATE AND VERIFIED QUESTIONS COVERING
FOUNDATIONAL NURSING CONCEPTS SUCH AS THE NURSING
PROCESS, CRITICAL THINKING, PATIENT SAFETY,
COMMUNICATION, AND EVIDENCE BASED PRACTICE
The nurse reviewing laboratory blood results will expect to observe which cation in the most
abundance? - ANSWER-Correct Answer:
Sodium
Explanation:
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular
cation. Chloride is an anion (negatively charged) rather than a cation (positively charged).
Magnesium is found predominantly inside cells and in bone. Which of these electrolytes would
have the greatest affect on BP?
A client is on complete bowel rest. What will the nurse tell the client about his diet? - ANSWER-
Correct Answer:
You will be receiving total parenteral nutrition (TPN).
Explanation:
Complete bowel rest involves giving your digestive system a break from eating any food by
mouth. TPN allows bowel rest while supplying adequate calorific intake and essential nutrients,
and removes antigenic mucosal stimuli. The BRAT diet (Bananas, Rice, Applesauce, Toast) was
once a staple of most pediatricians' recommendations for children with an upset stomach. It is
generally no longer recommended. Increasing fluids is appropriate for clients with dehydration,
not complete bowel rest. Eating a variety of foods is generally recommended for all clients
unless there are medical contraindications.
1|Page
,The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation
related to opioid use. Which outcome will the nurse evaluate as successful for the patient to
establish normal defecation? - ANSWER-The patient reports eliminating a soft, formed stool.
Explanation:
The nurse's goal is for the patient to take opioid medication and to have normal bowel
elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired
outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does
not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not
an indication of defecation.
The patient diagnosed with cardiovascular disease is receiving dietary instructions from the
nurse. Which information from the patient indicates teaching is successful? - ANSWER-Correct
Answer:
Limit cholesterol to less than 300 mg/day.
Explanation:
American Heart Association guidelines recommend limiting cholesterol to less than 300 mg/day.
Diet therapy includes eating fish at least 2 times per week and eating whole grain high-fiber
foods. Maintaining a prescribed carbohydrate intake is necessary for diabetes mellitus.
The patient has just started on enteral feedings, and is now reporting abdominal cramping.
Which action will the nurse take next? - ANSWER-Correct Answer:
Slow the rate of tube feeding.
Explanation:
One possible cause of abdominal cramping is a rapid increase in rate or volume. Lowering the
rate of delivery may increase tolerance. Another possible cause of abdominal cramping is the
use of cold formula. The nurse should warm the formula to room temperature. High-fat
formulas are also a cause of abdominal cramping.
2|Page
,The health care provider asks the nurse to monitor the fluid volume status of a heart failure
patient and a patient at risk for clinical dehydration. Which is the most effective nursing
intervention for monitoring both of these patients? - ANSWER-Correct Answer:
Weigh the patients every morning before breakfast
Explanation:
An effective measure of fluid retention or loss is daily weights; each kg (2.2 pounds) change is
equivalent to 1 L of fluid gained or lost. This measurement should be performed at the same
time every day using the same scale and the same amount of clothing. Although intake and
output records are important assessment measures, some patients are not able to keep their
own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit
but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs
with ECV excess but not with clinical dehydration.
A patient is experiencing oliguria. Which action should the nurse perform first? - ANSWER-
Correct Answer:
Assess for bladder distention.
Explanation:
Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all
assessment data to determine the potential cause of oliguria. It could be that the patient does
not have adequate intake, or it could be that the bladder sphincter is not functioning and the
patient is retaining water. Increasing fluids is effective if the patient does not have adequate
intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying
pathology is present. An order for diuretics can be obtained if the patient is retaining water, but
this should not be the first action.
Four patients arrive at the emergency department at the same time. Which patient will the
nurse see first? - ANSWER-Correct Answer:
An infant with temperature of 102.2° F and diarrhea for 3 days
3|Page
, Explanation:
The infant should be seen first. An infant's proportion of total body water (70% to 80% total
body weight) is greater than that of children or adults. Infants and young children have greater
water needs and immature kidneys. They are at greater risk for extracellular volume deficit and
hypernatremia because body water loss is proportionately greater per kilogram of weight. A
teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in
pain can wait as can an older adult with a blood pressure of 112/60.
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift
to occur in what direction? - ANSWER-Correct Answer:
From intracellular to extracellular
Explanation:
Hypertonic solutions (D5LR) will move fluid from the intracellular to the extracellular
(intravascular). A hypertonic solution has a concentration greater than normal body fluids, so
water will shift out of cells because of the osmotic pull of the extra particles. Movement of
water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids
(0.45%NS) are administered. Distribution of fluid between intravascular and interstitial spaces
occurs by filtration, the net sum of hydrostatic and osmotic pressures.
A patient has a decreased gag reflex, left-sided weakness, and drooling. Which action will the
nurse take when feeding this patient? - ANSWER-Correct Answer:
Flex head with chin-down.
Explanation:
Have the patient flex the head slightly to a chin-down position to help prevent aspiration. If the
patient has unilateral weakness, teach him or her and the caregiver to place food in the stronger
side of the mouth. Provide a 30-minute rest period before eating and position the patient in an
upright, seated position in a chair or raise the head of the bed to 90 degrees. Thin liquids such
as water and fruit juice are difficult to control in the mouth and are more easily aspirated.
4|Page
