NR 304 Final
Exam practice
Comprehensiv
e 302/304
Answers on
last page
1. Which assessment by the nurse most likely indicates that a patient is having
difficulty breathing?
18 breaths per minute and inhaled through the mouth
20 breathes per minute and shallow in character
16 breaths per minute and deep in character
28 breaths per minute and noisy
2.Which should a nurse always do when taking a rectal temperature?
Allow self-insertion of the thermometer.
Position the patient on the left side.
Use an electronic thermometer.
Lubricate the thermometer.
3. A nurse is assessing a patient’s ideal body weight. Which significant
factor should be takin into consideration when performing this
assessment?
Daily intake
height
Clothing size
Food preferences
,4. 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 from a:
Primary source
Tertiary sources
Subjective source
Secondary source
5. A nurse is preforming a physical assessment of a newly admitted patient.
Which patient statement communicates subjective data?
“I have sores between my toes.”
“I dye my hair but it is really gray.”
“My joints hurt when I get up in the morning.”
“My left leg drags on the floor when I am walking.”
6. A nurse takes a patient’s blood pressure and records a diastolic pressure of
120 mm Hg. Which should the nurse do first?
Notify the primary health-care provider.
Retake the blood pressure.
Notify the nurse in charge.
Take the other vital signs.
7.A patient had a stroke that resulted in paralysis of the right side. When
clustering data, the nurse grouped the following together: drooling of saliva
and slurred speech. Which information is most significant to include with
this clustered data?
Receptive aphasia
Inability to ambulate
Difficulty swallowing
Incontinence of bowel movements
, 8. A patient who experienced a stroke has left-sided hemiparesis and is
incontinent of urine. Which is an appropriately worded nursing diagnosis for this
patient?
The patient has a need to maintain skin integrity.
The patient has a stroked evidenced by hemiparesis and incontinence.
The patient will be clean and dry and will receive range-of-motion exercises every
four hours.
The patient is at risk for impaired skin integrity related to left-sided
hemiparesis and incontinence.
9. A nurse uses the interviewing process of clarification when interviewing a
patient. Which is the nurse doing when this communication technique is used?
Paraphrasing the patient’s message
Restating what the patient has said
Reviewing the patient’s communication
Verifying what is implied by the patient
10. A patient has dependent edema of the ankles and feet and is obese.
Which diet should the nurse expect the primary health-care provider to
order?
Low in sodium and high in fat
Low in sodium and low in calories
High in sodium and high in protein
High in sodium and low in carbohydrates
11. A patient who is undergoing cancer chemotherapy says to the nurse, “This
is no way to live.” Which response uses reflective techniques?
“Tell me more about what you are thinking.”
“You sound discouraged today.”
Exam practice
Comprehensiv
e 302/304
Answers on
last page
1. Which assessment by the nurse most likely indicates that a patient is having
difficulty breathing?
18 breaths per minute and inhaled through the mouth
20 breathes per minute and shallow in character
16 breaths per minute and deep in character
28 breaths per minute and noisy
2.Which should a nurse always do when taking a rectal temperature?
Allow self-insertion of the thermometer.
Position the patient on the left side.
Use an electronic thermometer.
Lubricate the thermometer.
3. A nurse is assessing a patient’s ideal body weight. Which significant
factor should be takin into consideration when performing this
assessment?
Daily intake
height
Clothing size
Food preferences
,4. 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 from a:
Primary source
Tertiary sources
Subjective source
Secondary source
5. A nurse is preforming a physical assessment of a newly admitted patient.
Which patient statement communicates subjective data?
“I have sores between my toes.”
“I dye my hair but it is really gray.”
“My joints hurt when I get up in the morning.”
“My left leg drags on the floor when I am walking.”
6. A nurse takes a patient’s blood pressure and records a diastolic pressure of
120 mm Hg. Which should the nurse do first?
Notify the primary health-care provider.
Retake the blood pressure.
Notify the nurse in charge.
Take the other vital signs.
7.A patient had a stroke that resulted in paralysis of the right side. When
clustering data, the nurse grouped the following together: drooling of saliva
and slurred speech. Which information is most significant to include with
this clustered data?
Receptive aphasia
Inability to ambulate
Difficulty swallowing
Incontinence of bowel movements
, 8. A patient who experienced a stroke has left-sided hemiparesis and is
incontinent of urine. Which is an appropriately worded nursing diagnosis for this
patient?
The patient has a need to maintain skin integrity.
The patient has a stroked evidenced by hemiparesis and incontinence.
The patient will be clean and dry and will receive range-of-motion exercises every
four hours.
The patient is at risk for impaired skin integrity related to left-sided
hemiparesis and incontinence.
9. A nurse uses the interviewing process of clarification when interviewing a
patient. Which is the nurse doing when this communication technique is used?
Paraphrasing the patient’s message
Restating what the patient has said
Reviewing the patient’s communication
Verifying what is implied by the patient
10. A patient has dependent edema of the ankles and feet and is obese.
Which diet should the nurse expect the primary health-care provider to
order?
Low in sodium and high in fat
Low in sodium and low in calories
High in sodium and high in protein
High in sodium and low in carbohydrates
11. A patient who is undergoing cancer chemotherapy says to the nurse, “This
is no way to live.” Which response uses reflective techniques?
“Tell me more about what you are thinking.”
“You sound discouraged today.”
