NR302 FINAL COMPREHENSIVE EXAM QUESTIONS AND ANSWERS /
NR 302 FINAL EXAM LATEST CHAMBERLAIN COLLEGE OF NURSING
WITH RATIONALES
1. 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: A respiratory rate of 28 breaths per minute is above the normal range (12-20 breaths per
minute), and noisy breathing (e.g., wheezing, stridor) indicates respiratory distress.
2. 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 reduces discomfort and prevents trauma to the rectal mucosa during insertion.
3. 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 preferences
Answer: B. Body height
Rationale: Ideal body weight is calculated based on height, as it provides a standardized measure for
determining healthy weight ranges.
,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:
A. Primary source
B. Tertiary source
C. Subjective source
D. Secondary source
Answer: D. Secondary source
Rationale: The patient's wife is a secondary source because she is providing information about the
patient rather than the patient providing it directly.
5. 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 on the floor when I am walking."
Answer: C. "My joints hurt when I get up in the morning."
Rationale: Subjective data is based on the patient's feelings or perceptions, such as pain, which cannot
be directly observed by the nurse.
6. 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: A diastolic pressure of 120 mm Hg is critically high and may indicate an error in
measurement. Retaking the blood pressure ensures accuracy before taking further action.
7. 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?
, A. The patient has a need to maintain skin integrity.
B. The patient has a stroke evidenced by hemiparesis and incontinence.
C. The patient will be clean and dry and will receive range-of-motion exercises every four hours.
D. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and incontinence.
Answer: D. The patient is at risk for impaired skin integrity related to left-sided hemiparesis and
incontinence.
Rationale: This diagnosis identifies a potential problem (impaired skin integrity) and links it to the
patient's specific conditions (hemiparesis and incontinence).
8. 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?
A. Receptive aphasia
B. Inability to ambulate
C. Difficulty swallowing
D. Incontinence of bowel movements
Answer: C. Difficulty swallowing
Rationale: Drooling and slurred speech are signs of dysphagia (difficulty swallowing), which is a common
complication of stroke and requires immediate attention.
9. A nurse uses the interviewing process of clarification when interviewing a patient. Which is the
nurse doing when this communication technique is used?
A. Paraphrasing the patient's message
B. Restating what the patient has said
C. Reviewing the patient's communication
D. Verifying what is implied by the patient
Answer: D. Verifying what is implied by the patient
Rationale: Clarification involves asking the patient to elaborate or confirm information to ensure the
nurse understands the patient's message accurately.
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?
A. Low in sodium and high in fat
B. Low in sodium and low in calories
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