NSG 300 Exam 3 V2 | NSG 300 Foundations of
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is assessing a client who has been bedridden for several days. Which of the
following findings should the nurse identify as a systemic effect of immobility? (Select All
That Apply)
A. Decreased basal metabolic rate
B. Increased cardiac output
C. Hypercalcemia
D. Pressure injury formation
E. Urinary stasis
F. Decreased gastric motility
Correct Answer: A, C, D, E, F
Explanation: Immobility affects multiple body systems by slowing down metabolic
processes and increasing calcium release from bones into the blood. Urinary stasis occurs
because the renal pelvis fills before urine enters the ureters in a supine position.
Additionally, the lack of movement decreases peristalsis and increases the risk of skin
breakdown due to prolonged pressure.
,2. A nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the
following nursing interventions is most effective in preventing further venous stasis?
A. Applying cold compresses to the affected extremity
B. Massaging the lower extremities daily
C. Placing pillows under the client’s knees
D. Encouraging early and frequent ambulation
Correct Answer: D
Explanation: Ambulation is the most effective way to promote venous return through the
action of the skeletal muscle pump. Massaging the legs is contraindicated as it may dislodge
a clot and lead to a pulmonary embolism. Placing pillows under the knees can actually
impede venous flow and should be avoided.
3. Which of the following interventions should a nurse implement to prevent respiratory
complications in an immobile client? (Select All That Apply)
A. Turning and positioning the client every 2 hours
B. Encouraging the use of an incentive spirometer every hour while awake
C. Restricting fluid intake to 1000 mL per day
D. Auscultating lung sounds every 4 to 8 hours
E. Instructing the client to perform deep-breathing and coughing exercises
Correct Answer: A, B, D, E
,Explanation: Frequent position changes help prevent the pooling of secretions and
atelectasis in the dependent areas of the lungs. Incentive spirometry and deep breathing
promote lung expansion and gas exchange. Adequate hydration is actually necessary to
keep secretions thin and easy to expectorate, so fluids should not be restricted unless
contraindicated.
4. A nurse is reviewing the laboratory results of a client who has been immobile for a month.
Which of the following results should the nurse expect?
A. Hypocalcemia
B. Hypernatremia
C. Negative nitrogen balance
D. Decreased serum protein
Correct Answer: C
Explanation: Immobility leads to the breakdown of muscle protein, which results in the
excretion of nitrogen. This state is known as negative nitrogen balance and indicates that
protein catabolism is exceeding anabolism. Monitoring nutritional intake and promoting
activity can help mitigate this metabolic effect.
5. A nurse is using the Braden Scale to assess a client’s risk for pressure injuries. Which factors
are included in this assessment? (Select All That Apply)
A. Sensory perception
B. Moisture
, C. Activity
D. Age
E. Nutrition
F. Friction and shear
Correct Answer: A, B, C, E, F
Explanation: The Braden Scale evaluates six subscales: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. Each category is scored, and a lower total
score indicates a higher risk for pressure injury development. Age is not a direct
component of the Braden Scale, although it can influence the individual subscale scores.
6. A nurse notes a client has a pressure injury that is characterized by partial-thickness loss of
dermis and a shallow, open ulcer with a red-pink wound bed without slough. How should the
nurse document this stage?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: C
Explanation: Stage 2 pressure injuries involve partial-thickness loss of the dermis
presenting as a shallow open ulcer or a ruptured/intact serum-filled blister. Stage 1
Nursing | Actual Q&A with Rationale (NSG300
Exam 3) | Grand Canyon University
1. A nurse is assessing a client who has been bedridden for several days. Which of the
following findings should the nurse identify as a systemic effect of immobility? (Select All
That Apply)
A. Decreased basal metabolic rate
B. Increased cardiac output
C. Hypercalcemia
D. Pressure injury formation
E. Urinary stasis
F. Decreased gastric motility
Correct Answer: A, C, D, E, F
Explanation: Immobility affects multiple body systems by slowing down metabolic
processes and increasing calcium release from bones into the blood. Urinary stasis occurs
because the renal pelvis fills before urine enters the ureters in a supine position.
Additionally, the lack of movement decreases peristalsis and increases the risk of skin
breakdown due to prolonged pressure.
,2. A nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the
following nursing interventions is most effective in preventing further venous stasis?
A. Applying cold compresses to the affected extremity
B. Massaging the lower extremities daily
C. Placing pillows under the client’s knees
D. Encouraging early and frequent ambulation
Correct Answer: D
Explanation: Ambulation is the most effective way to promote venous return through the
action of the skeletal muscle pump. Massaging the legs is contraindicated as it may dislodge
a clot and lead to a pulmonary embolism. Placing pillows under the knees can actually
impede venous flow and should be avoided.
3. Which of the following interventions should a nurse implement to prevent respiratory
complications in an immobile client? (Select All That Apply)
A. Turning and positioning the client every 2 hours
B. Encouraging the use of an incentive spirometer every hour while awake
C. Restricting fluid intake to 1000 mL per day
D. Auscultating lung sounds every 4 to 8 hours
E. Instructing the client to perform deep-breathing and coughing exercises
Correct Answer: A, B, D, E
,Explanation: Frequent position changes help prevent the pooling of secretions and
atelectasis in the dependent areas of the lungs. Incentive spirometry and deep breathing
promote lung expansion and gas exchange. Adequate hydration is actually necessary to
keep secretions thin and easy to expectorate, so fluids should not be restricted unless
contraindicated.
4. A nurse is reviewing the laboratory results of a client who has been immobile for a month.
Which of the following results should the nurse expect?
A. Hypocalcemia
B. Hypernatremia
C. Negative nitrogen balance
D. Decreased serum protein
Correct Answer: C
Explanation: Immobility leads to the breakdown of muscle protein, which results in the
excretion of nitrogen. This state is known as negative nitrogen balance and indicates that
protein catabolism is exceeding anabolism. Monitoring nutritional intake and promoting
activity can help mitigate this metabolic effect.
5. A nurse is using the Braden Scale to assess a client’s risk for pressure injuries. Which factors
are included in this assessment? (Select All That Apply)
A. Sensory perception
B. Moisture
, C. Activity
D. Age
E. Nutrition
F. Friction and shear
Correct Answer: A, B, C, E, F
Explanation: The Braden Scale evaluates six subscales: sensory perception, moisture,
activity, mobility, nutrition, and friction/shear. Each category is scored, and a lower total
score indicates a higher risk for pressure injury development. Age is not a direct
component of the Braden Scale, although it can influence the individual subscale scores.
6. A nurse notes a client has a pressure injury that is characterized by partial-thickness loss of
dermis and a shallow, open ulcer with a red-pink wound bed without slough. How should the
nurse document this stage?
A. Stage 1
B. Stage 3
C. Stage 2
D. Stage 4
Correct Answer: C
Explanation: Stage 2 pressure injuries involve partial-thickness loss of the dermis
presenting as a shallow open ulcer or a ruptured/intact serum-filled blister. Stage 1
