NUR 155: Exam 2: 50 Verified Questions & Answers:Updated A+
Score Guide Solution
Nursing Fundamentals: Nutrition, Elimination, and Clinical Assessment Study Guide
Question 1
A patient is being treated for fluid overload. What might you see in the patient's
care plan regarding nutrition therapy? (Select all that apply.)
• A. Patient is placed on fluid restrictions
• B. Patient is placed on a sodium-restricted diet
• C. Patient is encouraged to drink 1,500 mL of water
• D. Patient education on checking food labels for sodium content
Correct Answers: A, B, D
Rationale: Fluid volume excess (fluid overload/hypervolemia) requires
restricting fluid intake and restricting dietary sodium (which draws water and
increases blood volume). Patients must also learn to read labels to limit sodium
intake. Encouraging water consumption would worsen the overload.
Question 2
A patient who has a colostomy is complaining about having excess gas. You ask
the patient to tell you what he has eaten in the past 48 hours. Which food would
you suspect is causing the patient's excessive gas?
• A. Squash, Spinach, and Pickles
• B. Chicken, grapes, and raspberries
• C. Cherries, Radishes, and Watermelon
• D. Caraway seeds, tomato soup, and eggs
Correct Answer: C
Rationale: Cherries, radishes, and watermelon are foods known to cause
gas/flatulence in the intestinal tract.
Question 3
A patient is diagnosed with Congestive Heart Failure (CHF) and must follow a
specific diet. Which spices are okay for the patient to use daily?
• A. Garlic Sodium & Nutmeg
• B. Sea Salt & Pepper
, • C. Onion Salt & Garlic Powder
• D. Ginger & Bay Leaves
Correct Answer: D
Rationale: Patients with CHF require a strict sodium restriction. Sea salt, garlic
sodium, and onion salt contain high amounts of sodium. Ginger and bay leaves
do not contain sodium and are safe daily alternatives to add flavor.
Question 4
A patient with gout should follow what type of diet?
• A. High-calcium diet
• B. Renal Diet
• C. Low-purine diet
• D. Potassium-modified diet
Correct Answer: C
Rationale: A low-purine diet is clinically indicated to manage and minimize
gout flares.
Question 5
The client who was started on total parenteral nutrition (TPN) yesterday has the
following morning lab results. Which result indicates the greatest urgency for the
nurse's collaboration with the physician?
• A. Potassium of 2.5
• B. Serum glucose of 228
• C. BUN of 60
• D. Prealbumin of 15
Correct Answer: A
Rationale: The normal range for potassium is 3.5 to 5.0 mEq/L. A potassium
level of 2.5 mEq/L represents severe hypokalemia, which poses an immediate,
life-threatening risk for cardiac arrhythmias and requires urgent intervention.
Question 6
The nurse is creating a plan of care for a client receiving enteral feedings via a
gastrostomy tube (G-tube). The nurse should plan to include which intervention
in the plan of care?
, • A. Provide oral fluids 3 times per day
• B. Check around the stoma site for skin irritation
• C. Medicate with antidiarrheal medications every day
• D. Use sterile technique when administering the tube feedings
Correct Answer: B
Rationale: The nurse must inspect the G-tube stoma site regularly to monitor
for and prevent skin breakdown and irritation. Enteral feeding is a clean (not
sterile) medical aseptic procedure. Daily antidiarrheal medications are not
routinely indicated without a specific cause.
Question 7
The nurse instructs a client about a low-fat diet. Which menu selection indicates
that the client understands the nurse's instructions?
• A. Shrimp and bacon salad
• B. Liver, potato salad, sherbet
• C. Turkey breast, boiled rice, and fruit
• D. Lean hamburger steak and macaroni and cheese
Correct Answer: C
Rationale: Turkey breast, white rice, and fruit are naturally low-fat food
choices. Bacon, liver, and cheese products contain high amounts of fats and
should be restricted.
Question 8
A patient with tented skin turgor, dry mucous membranes, and decreased
urinary output is under the nurse's care. Which nursing intervention should be
included in the care plan for the patient?
• A. Administering I.V. and oral fluids
• B. Clustering necessary activities throughout the day
• C. Assessing color, odor, and amount of sputum
• D. Monitoring serum albumin and total protein levels
Correct Answer: A
Rationale: Tented skin turgor, dry mucous membranes, and decreased urine
output are classic signs of fluid volume deficit (dehydration), which requires
restoring hydration with oral and intravenous fluids.
Score Guide Solution
Nursing Fundamentals: Nutrition, Elimination, and Clinical Assessment Study Guide
Question 1
A patient is being treated for fluid overload. What might you see in the patient's
care plan regarding nutrition therapy? (Select all that apply.)
• A. Patient is placed on fluid restrictions
• B. Patient is placed on a sodium-restricted diet
• C. Patient is encouraged to drink 1,500 mL of water
• D. Patient education on checking food labels for sodium content
Correct Answers: A, B, D
Rationale: Fluid volume excess (fluid overload/hypervolemia) requires
restricting fluid intake and restricting dietary sodium (which draws water and
increases blood volume). Patients must also learn to read labels to limit sodium
intake. Encouraging water consumption would worsen the overload.
Question 2
A patient who has a colostomy is complaining about having excess gas. You ask
the patient to tell you what he has eaten in the past 48 hours. Which food would
you suspect is causing the patient's excessive gas?
• A. Squash, Spinach, and Pickles
• B. Chicken, grapes, and raspberries
• C. Cherries, Radishes, and Watermelon
• D. Caraway seeds, tomato soup, and eggs
Correct Answer: C
Rationale: Cherries, radishes, and watermelon are foods known to cause
gas/flatulence in the intestinal tract.
Question 3
A patient is diagnosed with Congestive Heart Failure (CHF) and must follow a
specific diet. Which spices are okay for the patient to use daily?
• A. Garlic Sodium & Nutmeg
• B. Sea Salt & Pepper
, • C. Onion Salt & Garlic Powder
• D. Ginger & Bay Leaves
Correct Answer: D
Rationale: Patients with CHF require a strict sodium restriction. Sea salt, garlic
sodium, and onion salt contain high amounts of sodium. Ginger and bay leaves
do not contain sodium and are safe daily alternatives to add flavor.
Question 4
A patient with gout should follow what type of diet?
• A. High-calcium diet
• B. Renal Diet
• C. Low-purine diet
• D. Potassium-modified diet
Correct Answer: C
Rationale: A low-purine diet is clinically indicated to manage and minimize
gout flares.
Question 5
The client who was started on total parenteral nutrition (TPN) yesterday has the
following morning lab results. Which result indicates the greatest urgency for the
nurse's collaboration with the physician?
• A. Potassium of 2.5
• B. Serum glucose of 228
• C. BUN of 60
• D. Prealbumin of 15
Correct Answer: A
Rationale: The normal range for potassium is 3.5 to 5.0 mEq/L. A potassium
level of 2.5 mEq/L represents severe hypokalemia, which poses an immediate,
life-threatening risk for cardiac arrhythmias and requires urgent intervention.
Question 6
The nurse is creating a plan of care for a client receiving enteral feedings via a
gastrostomy tube (G-tube). The nurse should plan to include which intervention
in the plan of care?
, • A. Provide oral fluids 3 times per day
• B. Check around the stoma site for skin irritation
• C. Medicate with antidiarrheal medications every day
• D. Use sterile technique when administering the tube feedings
Correct Answer: B
Rationale: The nurse must inspect the G-tube stoma site regularly to monitor
for and prevent skin breakdown and irritation. Enteral feeding is a clean (not
sterile) medical aseptic procedure. Daily antidiarrheal medications are not
routinely indicated without a specific cause.
Question 7
The nurse instructs a client about a low-fat diet. Which menu selection indicates
that the client understands the nurse's instructions?
• A. Shrimp and bacon salad
• B. Liver, potato salad, sherbet
• C. Turkey breast, boiled rice, and fruit
• D. Lean hamburger steak and macaroni and cheese
Correct Answer: C
Rationale: Turkey breast, white rice, and fruit are naturally low-fat food
choices. Bacon, liver, and cheese products contain high amounts of fats and
should be restricted.
Question 8
A patient with tented skin turgor, dry mucous membranes, and decreased
urinary output is under the nurse's care. Which nursing intervention should be
included in the care plan for the patient?
• A. Administering I.V. and oral fluids
• B. Clustering necessary activities throughout the day
• C. Assessing color, odor, and amount of sputum
• D. Monitoring serum albumin and total protein levels
Correct Answer: A
Rationale: Tented skin turgor, dry mucous membranes, and decreased urine
output are classic signs of fluid volume deficit (dehydration), which requires
restoring hydration with oral and intravenous fluids.
