NURS 240 Exam 2 Practice|| Exam
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A 23-year-old postpartum client is breastfeeding. The nurse has completed teaching
about dietary changes and is evaluating teaching effectiveness. Which of the following
statements by the client indicates that additional teaching is needed?
A. "I need to increase my calorie intake."
B. "I need to decrease my consumption of protein-rich foods."
C. "I need to increase my awareness of potential gas-forming foods in the diet."
D. "I should increase my fluid intake to help milk production and compensate for
nursing." - ANSWERS-The correct answer was: B
Rationale: The need for protein increases during lactation. Therefore, a statement
referring to a decrease in the consumption of protein is ill advised. All of the other
options reflect accurate statements by the client that will support breastfeeding, such as
increased caloric intake and awareness of potential gas-forming foods in the diet.
TORCH - ANSWERS-An acronym used to identify infectious disease that can cause
serious harm to the developing fetus; diseases include toxoplasmosis, rubella,
cytomegalovirus, and herpes simplex.
,Critical Periods - ANSWERS-Time period during the development of tissue and organ
systems in which cell division and differentiation in most rapid; these tissues and organs
have increased susceptibility to injurious substances at this time, hence the term, critical
period.
Teratogen - ANSWERS-Any agent that can cause development of abnormal structures
in developing embryo/fetus.
Gestational diabetes - ANSWERS-Emergence of altered glucose metabolism during the
term of pregnancy in a client with no clinical history of diabetes.
Hyperemesis gravidarum - ANSWERS-Nausea and vomiting during pregnancy
associated with severe fluid and electrolyte depletion that can adversely affect maternal
well-being and compromise nutritional status if the client is not restored to proper
hydration balance.
Failure to thrive - ANSWERS-Inadequate growth pattern during infancy that results in a
documented weight and/or height that is significantly below standards of growth.
Maximum heart rate - ANSWERS-A number calculated by taking 220 minus the age in
years; used to calculate target heart rates.
Physiological anemia of pregnancy - ANSWERS-Expected consequence during
pregnancy that arises from an increase in blood volume that results in hemodilution.
Target heart rate - ANSWERS-A range of percentages, usually 50-90%, into whicih an
individual's heart rate should fall during aerobic exercise; percentage depends on levels
of fitness; range calculated by taking each percentage times the maximum heart rate.
Nutritional stores - ANSWERS-Substances needed to support life processes and the
devleoping fetus.
,Nursing Bottle Syndrome - ANSWERS-State of dental disease and decay resulting from
prolonged exposure to substances high in glucose content.
Which of the following actions does the nurse place highest priority on when hanging a
bag of total parenteral nutrition (TPN) solution for a client receiving nutritional support?
A. Observe the skin area around the catheter site.
B. Verify the solution with another RN prior to hanging the TPN solution.
C. Remove the TPN solution immediately before hanging to minimize breakdown.
D. Place the client in high fowlers (sitting up at 90 degrees) during TPN therapy. -
ANSWERS-The correct answer was: B
Rationale: When hanging a bag of TPN solution, it is critical to have two RNs verify the
ingredients of the solution with the original order, and to check the client's armband prior
to hanging the solution. This is a form of therapy that requires following the Five Rights
of Medication Administration. Even though it is important to check the catheter site for
possible infection or inflammation, it is not the highest priority for this client. Option 3 is
incorrect because TPN solutions should be removed from the refrigerator one hour prior
to hanging in order to prevent administration of a "cold" fluid. Option 4 is incorrect as the
client does not have to remain in a high Fowler position throughout TPN therapy.
A client who is lactose intolerant is recovering from a surgical procedure. The nurse
plans for progression of diet as tolerated recognizing:
A. That the client will be able to progress from a clear liquid to a full liquid diet without
incidence based on resumption of bowel sounds and return of the gag reflex.
B. There is no impact with regard to diet progression with this client.
C. Diet can be progressed after a bowel movement indicating that bowel activity has
returned.
D. A full liquid diet may have to be altered due to lactose intolerance because these
diets are mainly composed of milk products. - ANSWERS-The correct answer was: D
Rationale: A client who is lactose intolerant has a difficulty in handling milk and dairy
products due to deficient lactase enzyme. Full liquid diets are based on milk and dairy
products. If a client is known to be lactose intolerant, the diet will have to be adjusted to
reflect lactose-reduced or lactose-free products in order to prevent gastrointestinal
irritation. Option 1 is incorrect because it does not reflect the added clinical condition of
lactose intolerance but rather merely refers to progression of diet. Option 2 is incorrect
as the condition of lactose intolerance does have an impact on diet patterns. Option 3 is
, incorrect because diet progression does not rely merely on the return of a bowel
movement pattern.
A client is placed on enteral feedings via nasogastric tube to meet nutritional goals.
Which of the following assessments should the nurse include in a plan of care in order
to maintain fluid balance?
A. Assess the skin area around the tube site.
B. Weigh the client every shift.
C. Maintain strict I&O and flush the tube once a day for patency.
D. Irrigate the tube with water as ordered and include this fluid in total I&O. -
ANSWERS-The correct answer was: D
Rationale: A client who is receiving enteral feedings via nasogastric tube can be at risk
to develop dehydration due to inadequate fluid intake. It is therefore important to irrigate
the tube with water as ordered (before and after feedings or medication administration)
and include these irrigations in the client's total I & O measurements. Option 1 is
incorrect because although inspection of the skin surrounding the tube is necessary, it
does not relate specifically to fluid balance. Option 2 is incorrect because although this
may provide important information about their hydration status, it is not the best answer.
Option 3 is incorrect as feeding tubes are not flushed once a day.
Which of the following measures could the nurse institute to decrease the occurrence of
diarrhea in a client receiving enteral tube feedings?
A. Increase the rate of infusion.
B. Decrease the volume of formula.
C. Stop all medications, as this is most likely the etiology of the diarrhea.
D. Monitor residual. - ANSWERS-The correct answer was: B
Rationale: A client who is experiencing diarrhea related to enteral feeding is unable to
process or handle the feeding. Adjustment of feeding rate and volume is needed in
order to decrease incidence of diarrhea. Option 1 is incorrect because an increase in
infusion rate could lead to an increased incidence of diarrhea. Option 3 is incorrect as
this may not be a feasible solution to the problem and may not be the etiology. Although
it is important to monitor the residual, it will not help to decrease the occurrence of
diarrhea.
2026 MOST Recent Tested,Actual Exam
Questions (2026) WITH Recent Newest
Verified And Well Analyzed Exam
Questions (Actual Exam 2026-2027)
Correct Detailed & Verified ANSWERS
(100% Accurate Solutions) ||ALREADY
GRADED A+||Exam Guarantee Pass!!
A 23-year-old postpartum client is breastfeeding. The nurse has completed teaching
about dietary changes and is evaluating teaching effectiveness. Which of the following
statements by the client indicates that additional teaching is needed?
A. "I need to increase my calorie intake."
B. "I need to decrease my consumption of protein-rich foods."
C. "I need to increase my awareness of potential gas-forming foods in the diet."
D. "I should increase my fluid intake to help milk production and compensate for
nursing." - ANSWERS-The correct answer was: B
Rationale: The need for protein increases during lactation. Therefore, a statement
referring to a decrease in the consumption of protein is ill advised. All of the other
options reflect accurate statements by the client that will support breastfeeding, such as
increased caloric intake and awareness of potential gas-forming foods in the diet.
TORCH - ANSWERS-An acronym used to identify infectious disease that can cause
serious harm to the developing fetus; diseases include toxoplasmosis, rubella,
cytomegalovirus, and herpes simplex.
,Critical Periods - ANSWERS-Time period during the development of tissue and organ
systems in which cell division and differentiation in most rapid; these tissues and organs
have increased susceptibility to injurious substances at this time, hence the term, critical
period.
Teratogen - ANSWERS-Any agent that can cause development of abnormal structures
in developing embryo/fetus.
Gestational diabetes - ANSWERS-Emergence of altered glucose metabolism during the
term of pregnancy in a client with no clinical history of diabetes.
Hyperemesis gravidarum - ANSWERS-Nausea and vomiting during pregnancy
associated with severe fluid and electrolyte depletion that can adversely affect maternal
well-being and compromise nutritional status if the client is not restored to proper
hydration balance.
Failure to thrive - ANSWERS-Inadequate growth pattern during infancy that results in a
documented weight and/or height that is significantly below standards of growth.
Maximum heart rate - ANSWERS-A number calculated by taking 220 minus the age in
years; used to calculate target heart rates.
Physiological anemia of pregnancy - ANSWERS-Expected consequence during
pregnancy that arises from an increase in blood volume that results in hemodilution.
Target heart rate - ANSWERS-A range of percentages, usually 50-90%, into whicih an
individual's heart rate should fall during aerobic exercise; percentage depends on levels
of fitness; range calculated by taking each percentage times the maximum heart rate.
Nutritional stores - ANSWERS-Substances needed to support life processes and the
devleoping fetus.
,Nursing Bottle Syndrome - ANSWERS-State of dental disease and decay resulting from
prolonged exposure to substances high in glucose content.
Which of the following actions does the nurse place highest priority on when hanging a
bag of total parenteral nutrition (TPN) solution for a client receiving nutritional support?
A. Observe the skin area around the catheter site.
B. Verify the solution with another RN prior to hanging the TPN solution.
C. Remove the TPN solution immediately before hanging to minimize breakdown.
D. Place the client in high fowlers (sitting up at 90 degrees) during TPN therapy. -
ANSWERS-The correct answer was: B
Rationale: When hanging a bag of TPN solution, it is critical to have two RNs verify the
ingredients of the solution with the original order, and to check the client's armband prior
to hanging the solution. This is a form of therapy that requires following the Five Rights
of Medication Administration. Even though it is important to check the catheter site for
possible infection or inflammation, it is not the highest priority for this client. Option 3 is
incorrect because TPN solutions should be removed from the refrigerator one hour prior
to hanging in order to prevent administration of a "cold" fluid. Option 4 is incorrect as the
client does not have to remain in a high Fowler position throughout TPN therapy.
A client who is lactose intolerant is recovering from a surgical procedure. The nurse
plans for progression of diet as tolerated recognizing:
A. That the client will be able to progress from a clear liquid to a full liquid diet without
incidence based on resumption of bowel sounds and return of the gag reflex.
B. There is no impact with regard to diet progression with this client.
C. Diet can be progressed after a bowel movement indicating that bowel activity has
returned.
D. A full liquid diet may have to be altered due to lactose intolerance because these
diets are mainly composed of milk products. - ANSWERS-The correct answer was: D
Rationale: A client who is lactose intolerant has a difficulty in handling milk and dairy
products due to deficient lactase enzyme. Full liquid diets are based on milk and dairy
products. If a client is known to be lactose intolerant, the diet will have to be adjusted to
reflect lactose-reduced or lactose-free products in order to prevent gastrointestinal
irritation. Option 1 is incorrect because it does not reflect the added clinical condition of
lactose intolerance but rather merely refers to progression of diet. Option 2 is incorrect
as the condition of lactose intolerance does have an impact on diet patterns. Option 3 is
, incorrect because diet progression does not rely merely on the return of a bowel
movement pattern.
A client is placed on enteral feedings via nasogastric tube to meet nutritional goals.
Which of the following assessments should the nurse include in a plan of care in order
to maintain fluid balance?
A. Assess the skin area around the tube site.
B. Weigh the client every shift.
C. Maintain strict I&O and flush the tube once a day for patency.
D. Irrigate the tube with water as ordered and include this fluid in total I&O. -
ANSWERS-The correct answer was: D
Rationale: A client who is receiving enteral feedings via nasogastric tube can be at risk
to develop dehydration due to inadequate fluid intake. It is therefore important to irrigate
the tube with water as ordered (before and after feedings or medication administration)
and include these irrigations in the client's total I & O measurements. Option 1 is
incorrect because although inspection of the skin surrounding the tube is necessary, it
does not relate specifically to fluid balance. Option 2 is incorrect because although this
may provide important information about their hydration status, it is not the best answer.
Option 3 is incorrect as feeding tubes are not flushed once a day.
Which of the following measures could the nurse institute to decrease the occurrence of
diarrhea in a client receiving enteral tube feedings?
A. Increase the rate of infusion.
B. Decrease the volume of formula.
C. Stop all medications, as this is most likely the etiology of the diarrhea.
D. Monitor residual. - ANSWERS-The correct answer was: B
Rationale: A client who is experiencing diarrhea related to enteral feeding is unable to
process or handle the feeding. Adjustment of feeding rate and volume is needed in
order to decrease incidence of diarrhea. Option 1 is incorrect because an increase in
infusion rate could lead to an increased incidence of diarrhea. Option 3 is incorrect as
this may not be a feasible solution to the problem and may not be the etiology. Although
it is important to monitor the residual, it will not help to decrease the occurrence of
diarrhea.
