NR 302 Final Exam Review QUESTIONS AND ANSWERS ALL CORRECT
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On
assessment of the client, the nurse should expect to note which finding?
1. Increasing rate and depth of respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration Correct Answer: 1.
Increasing rate and depth of respirations with periods of apnea. pg. 434
A client diagnosed with conductive hearing loss (physical obstruction) asks the nurse to explain
the cause of the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem?
1. A deficit in the cochlea
2. A deficit in cranial nerve VIII
3. A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex Correct Answer: 3. A physical
obstruction to the transmission of sound waves
The nurse is testing the extra ocular movements in a client to assess for muscle weakness in the
eyes. The nurse should implement which assessment technique to assess for muscle weakness in
the eye?
1. Test corneal reflexes
2. Test 6 cardinal positions of gaze
3. Test visual acuity, using Snellen eye chart
4. Test sensory function by asking client to close the eyes and then lightly touching the forehead,
cheeks, chin Correct Answer: 2. Test 6 cardinal positions of gaze
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which
type of adventitious lung sounds should the nurse expect to hear when performing a respiratory
assessment on this client?
1. Stridor
2. Crackles
3. Wheezes
4. Diminishe Correct Answer: 3. Wheezes
high pitched squeaking sound
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen
chart is 20/30. How should the nurse explain these results to the client?
1. You have normal vision
, 2. You have some degree of blindness
3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft
4. You can read at a distance of 30 ft what a person with normal vision can read at 20 ft Correct
Answer: 3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft
The nurse performing a neurological exam is assessing eye movement to evaluate cranial nerves
III, IV, VI. Using a flashlight, the nurse would perform which action to obtain assessment data?
1. turn the flashlight on directly in front of the eye and watch for a response
2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze
3. instruct the client to look straight ahead, and then shine the flashlight from the temporal area
to the eye
4. Check pupil size, then ask the client to alternate looking at the flashlight and the examiner's
finger Correct Answer: 2. Ask the client to follow the flashlight through the 6 cardinal positions
of gaze
A client is diagnosed with external otitis (swimmers ear). Which finding would the nurse expect
to note on the assessment of the client?
1. A wider than normal ear canal
2. A pearly gray tympanic membrane
3. Redness and swelling in the ear canal
4. An excessive amount of cerement lodged in the ear canal Correct Answer: 3. Redness and
swelling in the ear canal
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item
needed to perform this test?
1. A tuning fork
2. A stethoscope
3. A tongue blade
4. A reflex hammer Correct Answer: 1. A tuning fork
A nursing student is performing a respiratory assessment on a female adult client and is assessing
for tactile remits. Which action by the nursing student indicated a need for further teaching?
1. Palpating over the lung apices in the supraclavicular area
2. Asking the client to repeat the word ninety-nine during palpation
3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other
4. Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine
Correct Answer: 3. Palpating over the breast tissue to assess and compare vibrations from 1 side
to the other
bc sound will be muffled
The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On
assessment of the client, the nurse should expect to note which finding?
1. Increasing rate and depth of respirations with periods of apnea
2. Regular rapid and deep, sustained respirations
3. Totally irregular respiration in rhythm and depth
4. Irregular respirations with pauses at the end of inspiration and expiration Correct Answer: 1.
Increasing rate and depth of respirations with periods of apnea. pg. 434
A client diagnosed with conductive hearing loss (physical obstruction) asks the nurse to explain
the cause of the hearing problem. The nurse plans to explain to the client that this condition is
caused by which problem?
1. A deficit in the cochlea
2. A deficit in cranial nerve VIII
3. A physical obstruction to the transmission of sound waves
4. A defect in the sensory fibers that lead to the cerebral cortex Correct Answer: 3. A physical
obstruction to the transmission of sound waves
The nurse is testing the extra ocular movements in a client to assess for muscle weakness in the
eyes. The nurse should implement which assessment technique to assess for muscle weakness in
the eye?
1. Test corneal reflexes
2. Test 6 cardinal positions of gaze
3. Test visual acuity, using Snellen eye chart
4. Test sensory function by asking client to close the eyes and then lightly touching the forehead,
cheeks, chin Correct Answer: 2. Test 6 cardinal positions of gaze
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which
type of adventitious lung sounds should the nurse expect to hear when performing a respiratory
assessment on this client?
1. Stridor
2. Crackles
3. Wheezes
4. Diminishe Correct Answer: 3. Wheezes
high pitched squeaking sound
The nurse is reviewing a client's record and notes that the result of a vision test using a Snellen
chart is 20/30. How should the nurse explain these results to the client?
1. You have normal vision
, 2. You have some degree of blindness
3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft
4. You can read at a distance of 30 ft what a person with normal vision can read at 20 ft Correct
Answer: 3. You can read at a distance of 20 ft what a person with normal vision can read at 30 ft
The nurse performing a neurological exam is assessing eye movement to evaluate cranial nerves
III, IV, VI. Using a flashlight, the nurse would perform which action to obtain assessment data?
1. turn the flashlight on directly in front of the eye and watch for a response
2. Ask the client to follow the flashlight through the 6 cardinal positions of gaze
3. instruct the client to look straight ahead, and then shine the flashlight from the temporal area
to the eye
4. Check pupil size, then ask the client to alternate looking at the flashlight and the examiner's
finger Correct Answer: 2. Ask the client to follow the flashlight through the 6 cardinal positions
of gaze
A client is diagnosed with external otitis (swimmers ear). Which finding would the nurse expect
to note on the assessment of the client?
1. A wider than normal ear canal
2. A pearly gray tympanic membrane
3. Redness and swelling in the ear canal
4. An excessive amount of cerement lodged in the ear canal Correct Answer: 3. Redness and
swelling in the ear canal
The nurse is preparing to perform a Weber test on a client. The nurse should obtain which item
needed to perform this test?
1. A tuning fork
2. A stethoscope
3. A tongue blade
4. A reflex hammer Correct Answer: 1. A tuning fork
A nursing student is performing a respiratory assessment on a female adult client and is assessing
for tactile remits. Which action by the nursing student indicated a need for further teaching?
1. Palpating over the lung apices in the supraclavicular area
2. Asking the client to repeat the word ninety-nine during palpation
3. Palpating over the breast tissue to assess and compare vibrations from 1 side to the other
4. Comparing vibrations from 1 side to the other as the client repeats the word ninety-nine
Correct Answer: 3. Palpating over the breast tissue to assess and compare vibrations from 1 side
to the other
bc sound will be muffled
