NR304 final practice questions | Cheat Sheet Health sciences

NR304 FINAL EXAM PRACTICE QUESTIONS

1. During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next?

a. Document that the pulses are nonpalpable

b. Reassess the pulses in 1 hour

c. Ask the patient to turn to the side, and then palpate for the pulses again

d. Use a Doppler device to assess the pulses

2. The nurse is unable to palpate the right radial pulse on a patient. The best action would be to:

a. Auscultate over the area with a fetoscope

b. Use a goniometer to measure the pulsations

c. Use a Doppler device to check for pulsations over the area

d. Check for the presence of pulsations with a stethoscope

3. A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the:

a. Menstrual history, because it is generally non-threatening

b. Obstetric history, because it includes the most important information

c. Urinary system history, because problems may develop in this area as well

d. Sexual history, because discussing it first will build rapport

4. A nurse is teaching a client who was recently diagnosed with Raynaud’s disease about preventing the onset of manifestations. Which of the

following statements by the client indicates an understanding of the teaching?

a. “I should limit my exposure to sunlight”

b. “I should avoid drinking alcohol”

c. “I should not smoke”

d. “I should limit intake of foods that are high in purine”

5. A nurse is determining a client’s risk for developing osteoporosis. The nurse should identify which of the following as risk factors for bone

loss? (Select all that apply)

a. Small body frame

b. Hypertension

c. African-American ethnicity

d. Low vitamin D intake

e. Smoking

6. A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves

is the nurse teaching?

a. Cranial nerve XII

b. Cranial nerve X

c. Cranial nerve VIII

d. Cranial nerve V

7. A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use?

a. Have the client open his mouth and say, “ahh”

b. Ask the client to identify the scent of coffee

c. Use a tongue blade to provoke a gag reflex

d. Have the client smile and raise his eyebrows

8. A nurse is performing a focused assessment of a client’s peripheral vascular system. In which of the following locations should the nurse

palpate the posterior tibial pulse?

a. Below the medial malleolus

b. In the popliteal fossa

c. In the antecubital space

d. On the dorsum of the foot

9. During a health history, a 22-year-old woman asks, “Can I ge that vaccine for human papillomavirus (HPV)? I have genital warts and I’d like

them to go away!” What is the nurse’s best response?

a. “The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today”

b. “This vaccine is only for girls who have not yet started to become sexually active”

c. “Let’s check with the physician to see if you are a candidate for this vaccine”

d. “The vaccine cannot protect you if you already have an HPV infection”

10. A nurse is performing a cranial nerve assessment on a patient. Which of the following tests examines the function of CN III?

a. PERRLA and 6 cardinal gazes

b. Visual acuity

c. Whisper test

d. Cotton ball feeling

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During an assessment, the nurse is unable to palpate pulses in the left lower leg. What should the nurse do next? a. Document that the pulses are nonpalpable b. Reassess the pulses in 1 hour c. Ask the patient to turn to the side, and then palpate for the pulses again d. Use a Doppler device to assess the pulses
The nurse is unable to palpate the right radial pulse on a patient. The best action would be to: a. Auscultate over the area with a fetoscope b. Use a goniometer to measure the pulsations c. Use a Doppler device to check for pulsations over the area d. Check for the presence of pulsations with a stethoscope
A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: a. Menstrual history, because it is generally non-threatening b. Obstetric history, because it includes the most important information c. Urinary system history, because problems may develop in this area as well d. Sexual history, because discussing it first will build rapport
A nurse is teaching a client who was recently diagnosed with Raynaud’s disease about preventing the onset of manifestations. Which of the following statements by the client indicates an understanding of the teaching? a. “I should limit my exposure to sunlight” b. “I should avoid drinking alcohol” c. “I should not smoke” d. “I should limit intake of foods that are high in purine”
A nurse is determining a client’s risk for developing osteoporosis. The nurse should identify which of the following as risk factors for bone loss? ( Select all that apply ) a. Small body frame b. Hypertension c. African-American ethnicity d. Low vitamin D intake e. Smoking
A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse teaching? a. Cranial nerve XII b. Cranial nerve X c. Cranial nerve VIII d. Cranial nerve V
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? a. Have the client open his mouth and say, “ahh” b. Ask the client to identify the scent of coffee c. Use a tongue blade to provoke a gag reflex d. Have the client smile and raise his eyebrows
A nurse is performing a focused assessment of a client’s peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? a. Below the medial malleolus b. In the popliteal fossa c. In the antecubital space d. On the dorsum of the foot
During a health history, a 22-year-old woman asks, “Can I ge that vaccine for human papillomavirus (HPV)? I have genital warts and I’d like them to go away!” What is the nurse’s best response? a. “The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today” b. “This vaccine is only for girls who have not yet started to become sexually active” c. “Let’s check with the physician to see if you are a candidate for this vaccine” d. “The vaccine cannot protect you if you already have an HPV infection”
A nurse is performing a cranial nerve assessment on a patient. Which of the following tests examines the function of CN III? a. PERRLA and 6 cardinal gazes b. Visual acuity c. Whisper test d. Cotton ball feeling

Which nursing actions are appropriate for preventing skin breakdown of a client with a spinal cord injury and paralysis? Select all that apply. a. Massage over erythematous bony prominences b. Implement a turning schedule every 4 hours c. Use pillows to keep heels off the bed d. Keep skins dry with powder e. Minimize skin exposure to moisture
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? a. Place the client in the Trendelenburg position b. Perform percussions directly over the client’s bar skin c. Use a flattened hand to perform percussions d. Remind the client that chest percussions can cause mild pain
A nurse is providing teaching to an older adult client who has osteoarthritis of the right hip and lower lumber vertebrae. Which of the following statements by the client indicates an understanding of the teaching? a. “I should avoid using a heating pad on my back” b. “To relieve the pressure on my hip, I can use a cane while ambulating” c. “I will receive steroid injections in my joints to treat my pain” d. “I will exercise even when I feel pain”
A nurse in an acute care clinic is talking with a client who reports that the osteoarthritis pain in her knee is increasing each day. The client wants to discuss non-pharmacological approaches to help relieve her pain. Which of the following interventions should the nurse suggest? a. Applying warm compresses to sore joints b. Decreasing the daily intake of dietary protein c. Keeping joints in extension during rest periods d. Limiting sleep to 6 to 7 hr per night
A nurse is assessing a female who reports severe joint pain. The nurse should identify which of the following factors places the client at risk for gout? a. Perimenopause b. Migraine headaches c. Diuretic use d. Irritable bowel syndrome
A nurse is caring for an older adult client who has gout. Which of the following beverages should the nurse recommend that the client avoid? a. Alcohol b. Soda c. Coffee d. Orange juice
A nurse is caring for an older adult client who has gout and refuses to eat. The client’s provider has authorized the client’s family to bring food from home. Which of the following beverages/foods should the nurse recommend that the client avoid? a. Lentil soup b. Soda c. Coffee d. Orange juice
A nurse is assessing a client who has several risk factors for osteoporosis. Which of the following findings indicates that the client requires further evaluation for this disorder? a. Leg cramps with exercise b. Stress incontinence c. Abdominal distension d. Lower back pain

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate? a. Obtaining a detailed health history of the patient’s allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable risk factor? ( Select all that apply ) a. Genetic b. Hypercholesterolemia c. Hypertension d. Obesity e. Smoking
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client’s comfort? a. Rub the client’s feet briskly for several minutes b. Obtain a pair of slipper socks for the client c. Increase the client’s oral fluid intake d. Place a moist heating pad under the client’s feet
The perioperative nurse is providing care for a patient who is recovering in the postsurgical unit following a transurethral prostate resection (TURP). The patient is reluctant to ambulate, citing the need to recover in bed. For what complication is the patient most at risk? a. Atelectasis b. Anemia c. Dehydration d. Peripheral edema
The nurse is assessing a patient, who has many risk factors for the development of deep-vein thrombosis (DVT), for signs and symptoms of DVT. What signs and symptoms below would possibly indicate DVT is present? a. Cool extremity b. Decreased pulses c. Redness d. Pain e. Warm extremity f. Swelling g. Cyanosis
How should the nurse document mild, slightly pitting edema of the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. Widened pulse pressure b. Tachycardia c. Periorbital edema d. Decrease in urine output
A nurse is caring for a client who experiences a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? a. Battle’s sign b. Periorbital edema c. Dilated pupils d. Halo sign
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. The client rigidly extends his arms b. The client internally flexes his wrists c. The client curls into a fetal position d. The client internally rotates his legs
A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? a. Hypothalamus b. Cerebral cortex c. Pituitary d. Cerebellum
A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? a. Hypothalamus b. Cerebral cortex c. Brainstem d. Cerebellum
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband’s personality and ability to understand. He also cried very easily and becomes angry. The nurse recalls the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal
A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? a. Brain stem b. Hippocampus c. Parietal lobe d. Occipital lobe

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a. Flushing of the lower extremities b. Hypotension c. Tachycardia d. Report of a headache
When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight directly in front of the patient, and inspect for pupillary constriction b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose
A nurse is screening a client for skin cancer. When teaching the client about skin cancer risk, which of the following risk factors should the nurse include? a. Cigarette smoking b. Low-fiber deity c. Excessive exposure to ultraviolet light d. Human papillomavirus
A nurse is collecting a client’s health history. Which of the following findings is the highest risk for the client developing skin cancer? a. Age over 60 b. Genetic predisposition c. Light-skinned race d. Overexposure to sunlight
A nurse is providing an education program about dietary intervention to reduce the risk for prostate cancer. Which of the following information should the nurse include? a. Increase animal fat in the diet b. Increase fatty fish in the diet c. Reduce dietary fiber intake d. Increase complex carbohydrates in the diet
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment, what would the nurse expect to find when testing the patient’s deep tendon reflexes? a. Reflexes will be normal b. Reflexes cannot be elicited c. All reflexes will be diminished but present d. Some reflexes will be present, depending on the area of injury
While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor b. Uncooperative behavior c. Inability to understand questions d. Decreased level of consciousness
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? The patient’s response: a. Indicates a lesion of the cerebral cortex b. Indicates a completely nonfunctional brainstem c. Is normal and will go away in 24 to 48 hours d. Is a very ominous sign and may indicate brainstem injury

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? a. Decreased intake of phosphate-containing foods b. Spending several hours in the sun daily c. Increased estrogen levels d. History of anorexia nervosa
The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? a. Taking calcium and vitamin D supplements b. Taking medications to prevent osteoporosis c. Performing physical activity, such as fast walking d. Assessing bone density annually
A nurse is teaching an older adult client about osteoporosis. Which of the following statements should the nurse include in the teaching? a. “Cottage cheese is a good source of calcium” b. “Increase your caffeine intake” c. “Brisk walking will prevent bone loss” d. “Hormone replacement therapy with estrogen will increase your risk of osteoporosis”
A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis? a. Thyroid hormones b. Anticoagulants c. NSAIDs d. Cardiac glycosides
A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? a. Drinks one alcoholic beverage per day b. Smokes 1 pack of cigarettes per day c. Large body stature d. History of bone fracture during childhood
A nurse is teaching a client about risk factors for osteoporosis. Which of the following factors should the nurse include in the teaching? a. Sedentary lifestyle b. Obesity c. Aging d. Caffeine intake e. Secondhand smoke
A nurse is talking with a young adult client who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure? a. Increase sodium intake b. Have a bone-density scan each year c. Engage in weight-bearing exercise regularly d. Drink a cup of coffee each morning
A nurse is teaching a client about preventing osteoporosis. Which of the following statement by the cline indicates a need for further teaching? a. “I will reduce my intake of sodium” b. “I will decrease my intake of caffeine” c. “I will limit my intake of soft drinks” d. “I will reduce my intake of vitamin K-rich foods”

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take? a. Position the client supine with his legs elevated when in bed b. Encourage the client to ambulate for 15 min every hour while awake for the first 24 hr c. Tell the client to sit with his legs dependent after ambulating d. Instruct the client to wear knee-length socks for 2 weeks after surgery
A nurse is providing teaching about nutrients to a client. Which of the following statements should the nurse make? a. “Carbohydrates transport nutrients throughout the body” b. “Fats prevent ketosis” c. “Protein builds and repairs body tissue” d. “Carbohydrates help regulate body temperature”
A nurse is caring for a client who has a large wound healing by secondary intention. The nurse should inform the client that which of the following nutrients (in addition to protein) promotes wound healing? a. Vitamin B b. Calcium c. Vitamin C d. Potassium
A nurse is teaching a healthy older adult who has chronic constipation about establishing a bowel-retraining program. Which of the following statements should the nurse include in the teaching? a. “Limit physical activity during the day” b. “Set a time limit of 10 min when attempting to defecate” c. “Increase the fiber content of your diet” d. “Increase your fluid intake to 5,000 mL per day”
A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? a. Place suction equipment at the client’s bedside b. Apply an eye patch to the client’s right eye c. Avoid the use of warm water to wash the client’s face d. Provide ROM exercises to the client’s neck and shoulders
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient’s skin is warm and capillary refill time is normal. Next, the nurse should: a. Check for the presence of claudication b. Refer the individual for further evaluation c. Consider this finding normal, and proceed with the peripheral vascular evaluation d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm
The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. The patient is asked to assume the prone position b. The patient is asked to bend his or her knees to the side in a frog-like position c. The nurse firmly presses against the bone with the patient in a semi-Fowler’s position d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: a. Nonpitting, hard edema occurs with lymphatic obstruction b. Alterations in arterial function will cause edema c. Phlebitis of a superficial vein will cause bilateral edema d. Long-standing arterial obstruction will cause pitting edema

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client’s care? a. Impaired tissue perfusion b. Alteration in body image c. Alteration in activity tolerance d. Impaired skin integrity
A nurse is providing discharge instruction to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? a. Applying cool compresses to her legs b. Wearing loose, nonconstricting stockings c. Flexing her knees and feet frequently d. Taking an NSAID tablet daily
A nurse is assessing a client who is postoperative following a vaginal hysterectomy. Which of the following findings is a manifestation of deep-vein thrombosis (DVT)? a. Coolness of the leg or legs b. Decreased pedal pulses c. Pain in the ankle and foot d. Unilateral leg edema
A nurse is planning care for a client who has deep-vein thrombosis (DVT) and is receiving anticoagulant therapy. Which of the following interventions should the nurse include in the plan of care? a. Apply cold compresses to the affected extremity b. Massage the affected extremity gently c. Apply compression stockings at bedtime d. Encourage the client to walk
A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? a. “A weight loss program can decrease my LDL cholesterol level” b. “Exercising regularly will increase my HDL cholesterol levels” c. “Adding foods containing omega 3 fatty acids to my diet can lower m risk” d. “Increasing my intake of foods containing trans-fatty acids can lower my risk”
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? ( Select all that apply ) a. Take allopurinol as prescribed b. Exercise several times a week c. Limit intake of foods high in purine d. Decrease daily fluid intake e. Avoid citrus juices
A nurse on a medical unit is preparing to administer alendronate (bisphosphonate) 40 mg PO for an older adult client who has Paget’s disease of the bone. Which of the following actions should be the nurse’s priority? a. Administer the medication to the client before breakfast in the morning b. Ambulate the client to a chair prior to administering the medication c. Give the medication to the client with water rather than milk d. Teach the client how to take the medication at home

A patient is being seen in the clinic with complaints of “fainting episodes that started last week.” How should you proceed with the examination? a. Take the blood pressure in both arms and thighs b. Ask the person to walk a few paces and then take the blood pressure c. Record the blood pressure in the lying, sitting, and standing position d. Record the blood pressure in the lying and sitting positions and average these numbers to obtain a mean blood pressure
Gout is a type of arthritis that occurs due to the accumulation of __________ in the blood that causes needle-like crystals to form around the joints. a. Purines b. Creatinine c. Uric acid d. Amino acids
The nurse has completed a peripheral vascular assessment. Which of the following findings would he or she document as expected findings? a. Capillary refill <5 seconds b. Radial pulses 2+ with regular rate and rhythm bilaterally c. Right ankle 1+ edema with no perceptible swelling of the leg d. Feet pale and cool to touch
The emergency room nurse cares for a client demonstrating the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client’s friend tells the nurse that the client used hallucinogenic drugs. The nurse should take which of the following actions? a. Place the client on full restraints b. Decrease environmental stimuli c. Call the security guards d. Administer a PRN dose of chlorpromazine (Thorazine)
During a health history, a patient tells the nurse that he has trouble starting his urine stream. This problem is known as: a. Urgency b. Dribbling c. Frequency d. Hesitancy
A woman enters the clinic with complaints of difficulty with urination. What is the term to describe this? a. Stress incontinence b. Urge incontinence c. Urinary retention d. Fecal retention

NR304 final practice questions, Cheat Sheet of Health sciences

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