NR-302 FINAL COMPREHENSIVE EXAM
150 Questions with Correct Answers and Rationales
Q1. Which should a nurse always do when taking a rectal temperature?
a) Allow self-insertion of the thermometer
b) Position the patient on the left side
c) Use an electronic thermometer
d) Lubricate the thermometer
Answer: d) Lubricate the thermometer
Rationale: Lubrication prevents trauma to the rectal mucosa during insertion.
Positioning on the left side (Sims' position) is also recommended, but lubrication is
the always requirement for safety.
Q2. A nurse is assessing a patient's ideal body weight. Which significant factor
should be taken into consideration when performing this assessment?
a) Daily intake
b) Body height
c) Clothing size
d) Food preference
Answer: b) Body height
Rationale: Ideal body weight calculations are primarily based on height, with
adjustments for frame size. Height provides the baseline for weight norms.
Q3. A nurse asks a patient's wife specific questions about the patient's health
status before admission. When collecting this information, the nurse is seeking
information for a:
a) Primary source
b) Tertiary source
,c) Subjective source
d) Secondary source
Answer: d) Secondary source
Rationale: A secondary source is information obtained from someone other than
the patient (family member, caregiver, medical record). The patient is the primary
source.
Q4. A nurse is performing a physical assessment of a newly admitted patient.
Which patient statement communicates subjective data?
a) "I have sores between my toes"
b) "I dye my hair but it is really gray"
c) "My joints hurt when I get up in the morning"
d) "My left leg drags the floor when I am walking"
Answer: c) "My joints hurt when I get up in the morning"
Rationale: Subjective data are what the patient feels and reports. Pain, nausea,
dizziness, and fatigue are classic examples of subjective data. Objective data are
measurable/observable (sores, hair color, gait abnormalities).
Q5. Which is an example of nonverbal communications?
a) Letter
b) Holding hands
c) Noise in the room
d) Telephone message
Answer: b) Holding hands
Rationale: Nonverbal communication includes body language, touch, facial
expressions, and eye contact. Holding hands conveys empathy and presence
without spoken words.
Q6. A nurse takes a patient's blood pressure and records a diastolic pressure of
120 mm Hg. Which should the nurse do first?
a) Notify the primary health-care provider
,b) Retake the blood pressure
c) Notify the nurse in charge
d) Take the other vital signs
Answer: b) Retake the blood pressure
Rationale: An unexpected or abnormal finding should be verified before taking
action. A diastolic of 120 is severe hypertension; the nurse should recheck to
confirm accuracy, then notify the provider.
Q7. While making rounds, the nurse finds a patient on the floor in the hall.
Which should be the nurse's initial response?
a) Inspect the patient for injury
b) Transfer the patient back to bed
c) Move the patient to the closest chair
d) Report the patient's condition to the nurse manager
Answer: a) Inspect the patient for injury
Rationale: The priority is to assess for injury before moving the patient. Moving an
injured patient could cause further harm. After assessment, the nurse can
determine safe transfer.
Q8. Which should the nurse do to avoid patient accidents?
a) Provide a cane for walking if the patient is weak
b) Determine the strength of a patient before walking
c) Apply a vest restraint when a patient is using the wheelchair
d) Keep the overbed table in front of a patient sitting in a chair
Answer: b) Determine the strength of a patient before walking
Rationale: Assessing the patient's ability and strength before activity is a key fall
prevention strategy. Restraints should never be used for convenience, and
assistive devices must be properly fitted.
Q9. Which assessment by the nurse most likely indicates that a patient is having
difficulty breathing?
, a) 18 breaths per minute and inhaled through the mouth
b) 20 breaths per minute and shallow in character
c) 16 breaths per minute and deep in character
d) 28 breaths per minute and noisy
Answer: d) 28 breaths per minute and noisy
*Rationale: Tachypnea (rapid breathing) combined with noisy breathing
(wheezing, stridor, grunting) indicates respiratory distress. Normal adult rate is
12-20 breaths per minute.*
Q10. A patient returns to the surgical unit from the post-anesthesia care unit
after abdominal surgery. The primary health-care provider has written an order
to "Turn, cough, and deep breathe every 2 hours." The patient tells the nurse,
"It hurts too much to move." What should the nurse do first?
a) Explain the importance of turning, coughing, and deep breathing
b) Tell the patient that the primary health-care provider ordered it
c) Give the prescribed pain medication
d) Ask the patient to try to deep breathe while lying still
Answer: c) Give the prescribed pain medication
Rationale: Pain must be managed before the patient can effectively participate in
deep breathing and turning. The nurse should administer analgesics first, then
wait for peak effect before encouraging the activity.
Q11. A nurse is caring for a patient with a large pressure ulcer that has not
responded to common nursing interventions. With whom should the nurse
consult first to best deal with this problem?
a) Plastic surgeon
b) Physical therapist
c) Clinical nurse specialist
d) Primary health-care provider
Answer: c) Clinical nurse specialist
Rationale: A clinical nurse specialist (CNS) in wound care or gerontology has
150 Questions with Correct Answers and Rationales
Q1. Which should a nurse always do when taking a rectal temperature?
a) Allow self-insertion of the thermometer
b) Position the patient on the left side
c) Use an electronic thermometer
d) Lubricate the thermometer
Answer: d) Lubricate the thermometer
Rationale: Lubrication prevents trauma to the rectal mucosa during insertion.
Positioning on the left side (Sims' position) is also recommended, but lubrication is
the always requirement for safety.
Q2. A nurse is assessing a patient's ideal body weight. Which significant factor
should be taken into consideration when performing this assessment?
a) Daily intake
b) Body height
c) Clothing size
d) Food preference
Answer: b) Body height
Rationale: Ideal body weight calculations are primarily based on height, with
adjustments for frame size. Height provides the baseline for weight norms.
Q3. A nurse asks a patient's wife specific questions about the patient's health
status before admission. When collecting this information, the nurse is seeking
information for a:
a) Primary source
b) Tertiary source
,c) Subjective source
d) Secondary source
Answer: d) Secondary source
Rationale: A secondary source is information obtained from someone other than
the patient (family member, caregiver, medical record). The patient is the primary
source.
Q4. A nurse is performing a physical assessment of a newly admitted patient.
Which patient statement communicates subjective data?
a) "I have sores between my toes"
b) "I dye my hair but it is really gray"
c) "My joints hurt when I get up in the morning"
d) "My left leg drags the floor when I am walking"
Answer: c) "My joints hurt when I get up in the morning"
Rationale: Subjective data are what the patient feels and reports. Pain, nausea,
dizziness, and fatigue are classic examples of subjective data. Objective data are
measurable/observable (sores, hair color, gait abnormalities).
Q5. Which is an example of nonverbal communications?
a) Letter
b) Holding hands
c) Noise in the room
d) Telephone message
Answer: b) Holding hands
Rationale: Nonverbal communication includes body language, touch, facial
expressions, and eye contact. Holding hands conveys empathy and presence
without spoken words.
Q6. A nurse takes a patient's blood pressure and records a diastolic pressure of
120 mm Hg. Which should the nurse do first?
a) Notify the primary health-care provider
,b) Retake the blood pressure
c) Notify the nurse in charge
d) Take the other vital signs
Answer: b) Retake the blood pressure
Rationale: An unexpected or abnormal finding should be verified before taking
action. A diastolic of 120 is severe hypertension; the nurse should recheck to
confirm accuracy, then notify the provider.
Q7. While making rounds, the nurse finds a patient on the floor in the hall.
Which should be the nurse's initial response?
a) Inspect the patient for injury
b) Transfer the patient back to bed
c) Move the patient to the closest chair
d) Report the patient's condition to the nurse manager
Answer: a) Inspect the patient for injury
Rationale: The priority is to assess for injury before moving the patient. Moving an
injured patient could cause further harm. After assessment, the nurse can
determine safe transfer.
Q8. Which should the nurse do to avoid patient accidents?
a) Provide a cane for walking if the patient is weak
b) Determine the strength of a patient before walking
c) Apply a vest restraint when a patient is using the wheelchair
d) Keep the overbed table in front of a patient sitting in a chair
Answer: b) Determine the strength of a patient before walking
Rationale: Assessing the patient's ability and strength before activity is a key fall
prevention strategy. Restraints should never be used for convenience, and
assistive devices must be properly fitted.
Q9. Which assessment by the nurse most likely indicates that a patient is having
difficulty breathing?
, a) 18 breaths per minute and inhaled through the mouth
b) 20 breaths per minute and shallow in character
c) 16 breaths per minute and deep in character
d) 28 breaths per minute and noisy
Answer: d) 28 breaths per minute and noisy
*Rationale: Tachypnea (rapid breathing) combined with noisy breathing
(wheezing, stridor, grunting) indicates respiratory distress. Normal adult rate is
12-20 breaths per minute.*
Q10. A patient returns to the surgical unit from the post-anesthesia care unit
after abdominal surgery. The primary health-care provider has written an order
to "Turn, cough, and deep breathe every 2 hours." The patient tells the nurse,
"It hurts too much to move." What should the nurse do first?
a) Explain the importance of turning, coughing, and deep breathing
b) Tell the patient that the primary health-care provider ordered it
c) Give the prescribed pain medication
d) Ask the patient to try to deep breathe while lying still
Answer: c) Give the prescribed pain medication
Rationale: Pain must be managed before the patient can effectively participate in
deep breathing and turning. The nurse should administer analgesics first, then
wait for peak effect before encouraging the activity.
Q11. A nurse is caring for a patient with a large pressure ulcer that has not
responded to common nursing interventions. With whom should the nurse
consult first to best deal with this problem?
a) Plastic surgeon
b) Physical therapist
c) Clinical nurse specialist
d) Primary health-care provider
Answer: c) Clinical nurse specialist
Rationale: A clinical nurse specialist (CNS) in wound care or gerontology has
