NUR 2356 COMPREHENSIVE QUESTIONS AND
ANSWERS SET A+
✔✔Which actions would the nurse take for a patient who has diarrhea and is becoming
dehydrated? - ✔✔Monitor intake and output.
Weigh daily.
Assess skin turgor.
✔✔Which assessment cues alert the nurse that the patient with a fecal impaction is
deteriorating? - ✔✔Heart rate drops to 56 beats/min
Blood pressure elevates from 120/60 to 142/66 mm Hg
✔✔Which actions would the nurse take when performing routine ostomy care on a
patient with an ileostomy? - ✔✔Measure the stoma.
Assess the pouch seal.
Gently wash the stoma and peristomal area with water.
✔✔Which nursing actions would the nurse perform directly after completion of a
cleansing enema to an ambulatory patient? - ✔✔Assisting the patient to the bathroom
Ensuring that nonskid shoes/socks are in place
✔✔Which cues would alert the nurse that a patient with a nasogastric tube is
experiencing aspiration?
Correct - ✔✔Fever
Congested lung sounds
Shortness of breath
✔✔After how many enemas would the nurse notify the health care provider when the
patient's bowel return for cleansing enemas is still brown? - ✔✔3 enemas
✔✔Place the steps of ostomy care for a patient in the correct order. - ✔✔Remove and
dispose of the used ostomy pouch.
, Cleanse the area surrounding the stoma.
Assess the integrity of the stoma and peristomal skin.
Measure the stoma.
Prepare the new pouch to fit stoma.
Apply the new pouch.
✔✔Which actions taken by the nurse would be beneficial for meeting the patient's fluid
replacement needs after receiving a "force fluids" prescription for a fluid volume deficit?
Correct - ✔✔Ensuring the pitcher of water at the patient bedside is refilled as required
Providing ways to record intake of fluids to meet required levels
Tapering off fluid intake so the least amount is ingested before bedtime
Reminding the patient to drink throughout the day
✔✔Which data reflect the priority assessments that a nurse would monitor when
concerned that a patient may be developing a fluid volume imbalance? - ✔✔The
patient's pulse and blood pressure
The patient's weight changes over the past day
The patient's intake and output balance over the past 48 hours
✔✔Which substances would a nurse need to include in the fluid intake tally? -
✔✔Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
✔✔Which patient-related data would require entry of fluid output information on the
electronic health record (EHR)? - ✔✔The patient has a nasogastric (NG) tube attached
to wall suction.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
✔✔Which factors would be included by the nurse when developing a 24-hour fluid
budget for a patient with a 1000 mL fluid restriction? - ✔✔Medications
Intravenous (IV) fluids
Between-meal fluid sipping
Breakfast, lunch, and dinner
✔✔Which plan would a nurse suggest for the remainder of the 24-hour period for a
patient on a 1000 mL per day fluid restriction who has consumed 700 mL as of 3:00
p.m.? - ✔✔Allow 150 mL with dinner and 150 mL for medications and prior to going to
sleep.
ANSWERS SET A+
✔✔Which actions would the nurse take for a patient who has diarrhea and is becoming
dehydrated? - ✔✔Monitor intake and output.
Weigh daily.
Assess skin turgor.
✔✔Which assessment cues alert the nurse that the patient with a fecal impaction is
deteriorating? - ✔✔Heart rate drops to 56 beats/min
Blood pressure elevates from 120/60 to 142/66 mm Hg
✔✔Which actions would the nurse take when performing routine ostomy care on a
patient with an ileostomy? - ✔✔Measure the stoma.
Assess the pouch seal.
Gently wash the stoma and peristomal area with water.
✔✔Which nursing actions would the nurse perform directly after completion of a
cleansing enema to an ambulatory patient? - ✔✔Assisting the patient to the bathroom
Ensuring that nonskid shoes/socks are in place
✔✔Which cues would alert the nurse that a patient with a nasogastric tube is
experiencing aspiration?
Correct - ✔✔Fever
Congested lung sounds
Shortness of breath
✔✔After how many enemas would the nurse notify the health care provider when the
patient's bowel return for cleansing enemas is still brown? - ✔✔3 enemas
✔✔Place the steps of ostomy care for a patient in the correct order. - ✔✔Remove and
dispose of the used ostomy pouch.
, Cleanse the area surrounding the stoma.
Assess the integrity of the stoma and peristomal skin.
Measure the stoma.
Prepare the new pouch to fit stoma.
Apply the new pouch.
✔✔Which actions taken by the nurse would be beneficial for meeting the patient's fluid
replacement needs after receiving a "force fluids" prescription for a fluid volume deficit?
Correct - ✔✔Ensuring the pitcher of water at the patient bedside is refilled as required
Providing ways to record intake of fluids to meet required levels
Tapering off fluid intake so the least amount is ingested before bedtime
Reminding the patient to drink throughout the day
✔✔Which data reflect the priority assessments that a nurse would monitor when
concerned that a patient may be developing a fluid volume imbalance? - ✔✔The
patient's pulse and blood pressure
The patient's weight changes over the past day
The patient's intake and output balance over the past 48 hours
✔✔Which substances would a nurse need to include in the fluid intake tally? -
✔✔Nasogastric (NG) tube irrigations
Enteral tube feedings
Free water gastric tube flushes
Intravenous medications
✔✔Which patient-related data would require entry of fluid output information on the
electronic health record (EHR)? - ✔✔The patient has a nasogastric (NG) tube attached
to wall suction.
The patient has an indwelling urinary catheter in place.
The patient has a surgical wound drain on his abdomen.
✔✔Which factors would be included by the nurse when developing a 24-hour fluid
budget for a patient with a 1000 mL fluid restriction? - ✔✔Medications
Intravenous (IV) fluids
Between-meal fluid sipping
Breakfast, lunch, and dinner
✔✔Which plan would a nurse suggest for the remainder of the 24-hour period for a
patient on a 1000 mL per day fluid restriction who has consumed 700 mL as of 3:00
p.m.? - ✔✔Allow 150 mL with dinner and 150 mL for medications and prior to going to
sleep.
