NR 304 Final Exam practice
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Comprehensive 302/304
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Answers on last page
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1. Which Iassessment Iby Ithe Inurse Imost Ilikely Iindicates Ithat Ia Ipatient Iis Ihaving Idifficulty Ibreathing?
a. 18 Ibreaths Iper Iminute Iand Iinhaled Ithrough Ithe Imouth
b. 20 Ibreathes Iper Iminute Iand Ishallow Iin Icharacter
c. 16 Ibreaths Iper Iminute Iand Ideep Iin Icharacter
d. 28 Ibreaths Iper Iminute Iand Inoisy
2. Which Ishould Ia Inurse Ialways Ido Iwhen Itaking Ia Irectal Itemperature?
a. Allow Iself-insertion Iof Ithe Ithermometer.
b. Position Ithe Ipatient Ion Ithe Ileft Iside.
c. Use Ian Ielectronic Ithermometer.
d. Lubricate Ithe Ithermometer.
3. A Inurse Iis Iassessing Ia Ipatient’s Iideal Ibody Iweight. IWhich Isignificant Ifactor Ishould Ibe Itakin Iinto
Iconsideration Iwhen Iperforming Ithis Iassessment?
a. Daily Iintake
b. Body Iheight
c. Clothing Isize
d. Food Ipreferences
4. A Inurse Iasks Ia Ipatient’s Iwife Ispecific Iquestions Iabout Ithe Ipatient’s Ihealth Istatus Ibefore Iadmission.
IWhen Icollecting Ithis Iinformation, Ithe Inurse Iis Iseeking Iinformation Ifrom Ia:
a. Primary Isource
b. Tertiary Isources
c. Subjective Isource
d. Secondary Isource
5. A Inurse Iis Ipreforming Ia Iphysical Iassessment Iof Ia Inewly Iadmitted Ipatient. IWhich Ipatient Istatement
Icommunicates Isubjective Idata?
a. “I Ihave Isores Ibetween Imy Itoes.”
b. “I Idye Imy Ihair Ibut Iit Iis Ireally Igray.”
c. “My Ijoints Ihurt Iwhen II Iget Iup Iin Ithe Imorning.”
d. “My Ileft Ileg Idrags Ion Ithe Ifloor Iwhen II Iam Iwalking.”
,6. A Inurse Itakes Ia Ipatient’s Iblood Ipressure Iand Irecords Ia Idiastolic Ipressure Iof I120 Imm IHg. IWhich Ishould
Ithe Inurse Ido Ifirst?
a. Notify Ithe Iprimary Ihealth-care Iprovider.
b. Retake Ithe Iblood Ipressure.
c. Notify Ithe Inurse Iin Icharge.
d. Take Ithe Iother Ivital Isigns.
7. A Ipatient Ihad Ia Istroke Ithat Iresulted Iin Iparalysis Iof Ithe Iright Iside. IWhen Iclustering Idata, Ithe Inurse
Igrouped Ithe Ifollowing Itogether: Idrooling Iof Isaliva Iand Islurred Ispeech. IWhich Iinformation Iis Imost
Isignificant Ito Iinclude Iwith Ithis Iclustered Idata?
a. Receptive Iaphasia
b. Inability Ito Iambulate
c. Difficulty Iswallowing
d. Incontinence Iof Ibowel Imovements
8. A Ipatient Iwho Iexperienced Ia Istroke Ihas Ileft-sided Ihemiparesis Iand Iis Iincontinent Iof Iurine. IWhich Iis Ian
Iappropriately Iworded Inursing Idiagnosis Ifor Ithis Ipatient?
a. The Ipatient Ihas Ia Ineed Ito Imaintain Iskin Iintegrity.
b. The Ipatient Ihas Ia Istroked Ievidenced Iby Ihemiparesis Iand Iincontinence.
c. The Ipatient Iwill Ibe Iclean Iand Idry Iand Iwill Ireceive Irange-of-motion Iexercises Ievery Ifour Ihours.
d. The Ipatient Iis Iat Irisk Ifor Iimpaired Iskin Iintegrity Irelated Ito Ileft-sided Ihemiparesis Iand
Iincontinence.
9. A Inurse Iuses Ithe Iinterviewing Iprocess Iof Iclarification Iwhen Iinterviewing Ia Ipatient. IWhich Iis Ithe Inurse
Idoing Iwhen Ithis Icommunication Itechnique Iis Iused?
a. Paraphrasing Ithe Ipatient’s Imessage
b. Restating Iwhat Ithe Ipatient Ihas Isaid
c. Reviewing Ithe Ipatient’s Icommunication
d. Verifying Iwhat Iis Iimplied Iby Ithe Ipatient
10. A Ipatient Ihas Idependent Iedema Iof Ithe Iankles Iand Ifeet Iand Iis Iobese. IWhich Idiet Ishould Ithe Inurse
Iexpect Ithe Iprimary Ihealth-care Iprovider Ito Iorder?
a. Low Iin Isodium Iand Ihigh Iin Ifat
b. Low Iin Isodium Iand Ilow Iin Icalories
c. High Iin Isodium Iand Ihigh Iin Iprotein
d. High Iin Isodium Iand Ilow Iin Icarbohydrates
, 11. A Ipatient Iwho Iis Iundergoing Icancer Ichemotherapy Isays Ito Ithe Inurse, I“This Iis Ino Iway Ito Ilive.” IWhich
Iresponse Iuses Ireflective Itechniques?
a. “Tell Ime Imore Iabout Iwhat Iyou Iare Ithinking.”
b. “You Isound Idiscouraged Itoday.”
c. “Life Iis Inot Iworth Iliving?”
d. “What Iare Iyou Isaying?”
12. A Inurse Iis Iassessing Ia Ipatient Iwho Ireports Ibeing Iincontinent. IWhich Iquestion Ishould Ithe Inurse Iask Ito
Ielicit Iinformation Irelated Ito Iurge Iincontinence?
a. “Does Iurination Ioccur Iimmediately Iafter Icoughing?”
b. “Do Iyou Iurinate Ismall Iamounts Iof Iurine Ifrequently?”
c. “Do Iyou Ibegin Iurinating Iimmediately Iafter Ifeeling Ithe Ineed Ito Iurinate?”
d. “Does Iurination Ioccur Iat Ipredictable Iintervals Iwithout Ifeeling Ithe Ineed Ito Iurinate?”
13. Which Iis Ithe Imost Icommon Ireason Iwhy Iolder Iadults Ibecome Iincontinent Iof Iurine?
a. They Iuse Iincontinence Ito Imanipulate Iothers.
b. The Imuscles Ithat Icontrol Iurination Ibecome Iweak.
c. They Itend Ito Idrink Iless Ifluid Ithan Iyounger Ipatients.
d. Their Iincrease Iin Iweight Iplaces Ipressure Ion Ithe Ibladder.
14. What Iis Ithe Inurse Idoing Iwhen Iformulating Ia Inursing Idiagnosis?
a. Planning
b. Assessing
c. Analyzing
d. Implementing
15. A Ipatient Ihas Ijust Ireturned Ifrom Isurgery Iwith Ian Iintravenous Isolution Iinfusing Iand Idoes Inot Ihave Ia Igag
Ireflex. IWhich Iplanned Iintervention Itakes Ipriority?
a. Observe Ithe Idressing Ifor Idrainage.
b. Ensure Iadequacy Iof Iair Iexchange.
c. Check Ifor Ian Iinfiltration.
d. Monitor Ivital Isigns.
16. To Iprovide Iaseptically Isafe Iperineal Icare Ito Iall Ifemale Ipatients, Iwhich Ishould Ithe Inurse Ido?
I I I I
Comprehensive 302/304
I I
Answers on last page
I I I I
1. Which Iassessment Iby Ithe Inurse Imost Ilikely Iindicates Ithat Ia Ipatient Iis Ihaving Idifficulty Ibreathing?
a. 18 Ibreaths Iper Iminute Iand Iinhaled Ithrough Ithe Imouth
b. 20 Ibreathes Iper Iminute Iand Ishallow Iin Icharacter
c. 16 Ibreaths Iper Iminute Iand Ideep Iin Icharacter
d. 28 Ibreaths Iper Iminute Iand Inoisy
2. Which Ishould Ia Inurse Ialways Ido Iwhen Itaking Ia Irectal Itemperature?
a. Allow Iself-insertion Iof Ithe Ithermometer.
b. Position Ithe Ipatient Ion Ithe Ileft Iside.
c. Use Ian Ielectronic Ithermometer.
d. Lubricate Ithe Ithermometer.
3. A Inurse Iis Iassessing Ia Ipatient’s Iideal Ibody Iweight. IWhich Isignificant Ifactor Ishould Ibe Itakin Iinto
Iconsideration Iwhen Iperforming Ithis Iassessment?
a. Daily Iintake
b. Body Iheight
c. Clothing Isize
d. Food Ipreferences
4. A Inurse Iasks Ia Ipatient’s Iwife Ispecific Iquestions Iabout Ithe Ipatient’s Ihealth Istatus Ibefore Iadmission.
IWhen Icollecting Ithis Iinformation, Ithe Inurse Iis Iseeking Iinformation Ifrom Ia:
a. Primary Isource
b. Tertiary Isources
c. Subjective Isource
d. Secondary Isource
5. A Inurse Iis Ipreforming Ia Iphysical Iassessment Iof Ia Inewly Iadmitted Ipatient. IWhich Ipatient Istatement
Icommunicates Isubjective Idata?
a. “I Ihave Isores Ibetween Imy Itoes.”
b. “I Idye Imy Ihair Ibut Iit Iis Ireally Igray.”
c. “My Ijoints Ihurt Iwhen II Iget Iup Iin Ithe Imorning.”
d. “My Ileft Ileg Idrags Ion Ithe Ifloor Iwhen II Iam Iwalking.”
,6. A Inurse Itakes Ia Ipatient’s Iblood Ipressure Iand Irecords Ia Idiastolic Ipressure Iof I120 Imm IHg. IWhich Ishould
Ithe Inurse Ido Ifirst?
a. Notify Ithe Iprimary Ihealth-care Iprovider.
b. Retake Ithe Iblood Ipressure.
c. Notify Ithe Inurse Iin Icharge.
d. Take Ithe Iother Ivital Isigns.
7. A Ipatient Ihad Ia Istroke Ithat Iresulted Iin Iparalysis Iof Ithe Iright Iside. IWhen Iclustering Idata, Ithe Inurse
Igrouped Ithe Ifollowing Itogether: Idrooling Iof Isaliva Iand Islurred Ispeech. IWhich Iinformation Iis Imost
Isignificant Ito Iinclude Iwith Ithis Iclustered Idata?
a. Receptive Iaphasia
b. Inability Ito Iambulate
c. Difficulty Iswallowing
d. Incontinence Iof Ibowel Imovements
8. A Ipatient Iwho Iexperienced Ia Istroke Ihas Ileft-sided Ihemiparesis Iand Iis Iincontinent Iof Iurine. IWhich Iis Ian
Iappropriately Iworded Inursing Idiagnosis Ifor Ithis Ipatient?
a. The Ipatient Ihas Ia Ineed Ito Imaintain Iskin Iintegrity.
b. The Ipatient Ihas Ia Istroked Ievidenced Iby Ihemiparesis Iand Iincontinence.
c. The Ipatient Iwill Ibe Iclean Iand Idry Iand Iwill Ireceive Irange-of-motion Iexercises Ievery Ifour Ihours.
d. The Ipatient Iis Iat Irisk Ifor Iimpaired Iskin Iintegrity Irelated Ito Ileft-sided Ihemiparesis Iand
Iincontinence.
9. A Inurse Iuses Ithe Iinterviewing Iprocess Iof Iclarification Iwhen Iinterviewing Ia Ipatient. IWhich Iis Ithe Inurse
Idoing Iwhen Ithis Icommunication Itechnique Iis Iused?
a. Paraphrasing Ithe Ipatient’s Imessage
b. Restating Iwhat Ithe Ipatient Ihas Isaid
c. Reviewing Ithe Ipatient’s Icommunication
d. Verifying Iwhat Iis Iimplied Iby Ithe Ipatient
10. A Ipatient Ihas Idependent Iedema Iof Ithe Iankles Iand Ifeet Iand Iis Iobese. IWhich Idiet Ishould Ithe Inurse
Iexpect Ithe Iprimary Ihealth-care Iprovider Ito Iorder?
a. Low Iin Isodium Iand Ihigh Iin Ifat
b. Low Iin Isodium Iand Ilow Iin Icalories
c. High Iin Isodium Iand Ihigh Iin Iprotein
d. High Iin Isodium Iand Ilow Iin Icarbohydrates
, 11. A Ipatient Iwho Iis Iundergoing Icancer Ichemotherapy Isays Ito Ithe Inurse, I“This Iis Ino Iway Ito Ilive.” IWhich
Iresponse Iuses Ireflective Itechniques?
a. “Tell Ime Imore Iabout Iwhat Iyou Iare Ithinking.”
b. “You Isound Idiscouraged Itoday.”
c. “Life Iis Inot Iworth Iliving?”
d. “What Iare Iyou Isaying?”
12. A Inurse Iis Iassessing Ia Ipatient Iwho Ireports Ibeing Iincontinent. IWhich Iquestion Ishould Ithe Inurse Iask Ito
Ielicit Iinformation Irelated Ito Iurge Iincontinence?
a. “Does Iurination Ioccur Iimmediately Iafter Icoughing?”
b. “Do Iyou Iurinate Ismall Iamounts Iof Iurine Ifrequently?”
c. “Do Iyou Ibegin Iurinating Iimmediately Iafter Ifeeling Ithe Ineed Ito Iurinate?”
d. “Does Iurination Ioccur Iat Ipredictable Iintervals Iwithout Ifeeling Ithe Ineed Ito Iurinate?”
13. Which Iis Ithe Imost Icommon Ireason Iwhy Iolder Iadults Ibecome Iincontinent Iof Iurine?
a. They Iuse Iincontinence Ito Imanipulate Iothers.
b. The Imuscles Ithat Icontrol Iurination Ibecome Iweak.
c. They Itend Ito Idrink Iless Ifluid Ithan Iyounger Ipatients.
d. Their Iincrease Iin Iweight Iplaces Ipressure Ion Ithe Ibladder.
14. What Iis Ithe Inurse Idoing Iwhen Iformulating Ia Inursing Idiagnosis?
a. Planning
b. Assessing
c. Analyzing
d. Implementing
15. A Ipatient Ihas Ijust Ireturned Ifrom Isurgery Iwith Ian Iintravenous Isolution Iinfusing Iand Idoes Inot Ihave Ia Igag
Ireflex. IWhich Iplanned Iintervention Itakes Ipriority?
a. Observe Ithe Idressing Ifor Idrainage.
b. Ensure Iadequacy Iof Iair Iexchange.
c. Check Ifor Ian Iinfiltration.
d. Monitor Ivital Isigns.
16. To Iprovide Iaseptically Isafe Iperineal Icare Ito Iall Ifemale Ipatients, Iwhich Ishould Ithe Inurse Ido?
