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NSG-300 EXAM 2 NEWEST 2025 TEST BANK|
COMPLETE 400 REAL EXAM QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS WITH RATIONALES) GRADED A+
(BRAND NEW!!)
A client is on complete bowel rest. What will the nurse tell the client
about his diet? - 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.
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? - 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 1 / 4
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pg. 2 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? - 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? - 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.
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pg. 3 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? - 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? - 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. 3 / 4
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pg. 4 The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse?
- Necrotic tissue
- Presence of slough
- Granulation tissue
- Development of an infection - C) Granulation tissue
Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer?
- Height and weight
- Length and width
- Length and depth
- Width and depth - C) Length and width
Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer?
- Begin antibiotic therapy before the dressing change.
- Use appropriate personal protective equipment.
- Adhere to sterile technique during the intervention.
- Complete the dressing change in an effective, efficient manner. - B)
Use appropriate personal protective equipment.
The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction? - Correct
Answer: From intracellular to extracellular
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