NR 304 Exam 3
Student Name
Chamberlain University
NR-304: Health Assessment II
Prof. Name
Date
NR 304 – Exam 3 (Revised)
Which of the following are risk factors for deep vein thrombosis (DVT)? (Select all that apply)
A. Oral contraceptive use ✅
B. Immobility ✅
C. Venous insufficiency ✅
D. Physical activity
E. Calcium intakeFacial asymmetry and sagging during a cranial nerve assessment indicates dysfunction of which nerve?
A. Motor component of CN VII (7) ✅
B. Motor and sensory components of CN XI (11)
C. Motor component of CN X (10)
D. Motor component of CN IV (4)Which client statement about genital herpes indicates a need for further teaching?
A. “Abstaining from sexual activity reduces the risk of transmission of the disease”
B. “The use of condoms will reduce the risk of transmission”
C. “Antiviral medications will not cure the infection”
D. “Transmission of the disease will not occur when my lesions are gone” ✅What is the primary function of the thymus, spleen, and lymph nodes?
A. These organs assist vitamin absorption
B. These organs are used in digestion
C. These organs regulate electrolyte balance
D. These organs support immunity ✅Which findings are associated with urinary retention due to prostatic hypertrophy? (Select all that apply)
A. Voiding small amounts of urine frequently ✅
B. Report of feeling pressure ✅
C. Distended bladder ✅
D. Dysuria ✅
E. Tenderness over the symphysis pubis ✅Which is a manifestation of deep-vein thrombosis (DVT)?
A. Decreased pedal pulses
B. Pain in the ankle and foot
C. Coolness of the leg or legs
D. Unilateral leg edema ✅Which finding indicates that peristalsis is returning post abdominal surgery?
A. Abdominal distention
B. Hypoactive bowel sounds in two quadrants
C. Passage of flatus ✅
D. Request for a cup of tea and some toastWhich is a risk factor for the development of osteoporosis?
A. Long-term use of diuretics
B. Obesity
C. Sedentary lifestyle ✅
D. Prolonged stressWhat action should a nurse take to prevent infection in a client with a urinary catheter?
A. Replace the catheter every 3 days
B. Check the catheter tubing for kinks or twisting ✅
C. Irrigate the catheter once each shift
D. Clean the perineal area with an antiseptic solution dailyWhich client has a contraindication for oral contraceptives?
A. A 38-year-old client that reports smoking one pack of cigarettes every day ✅
B. A 28-year-old client with a history of pelvic inflammatory disease
C. A 32-year-old client with benign breast disease
D. A 26-year-old client with migraine headaches at the start of each menstrual cycleWhich of the following is a sign of hypoglycemia?
A. Flushed skin
B. Bradycardia
C. Diaphoresis ✅
D. Decreased respirationsWhat is the most accurate method for verifying placement of a nasogastric (NG) tube?
A. Aspirating stomach contents
B. Injecting air and listening with a stethoscope
C. Checking pH of aspirate
D. Chest x-ray ✅Which type of isolation precaution is required for a client with tuberculosis?
A. Droplet precautions
B. Contact precautions
C. Protective environment
D. Airborne precautions ✅A nurse should monitor a client receiving furosemide for which of the following?
A. Hyperkalemia
B. Hypokalemia ✅
C. Hypercalcemia
D. HypernatremiaWhich finding is most important to report to the provider for a client taking warfarin?
A. Occasional headaches
B. Bleeding gums ✅
C. Urinary frequency
D. NauseaWhich electrolyte imbalance is associated with muscle weakness and dysrhythmias?
A. Hypernatremia
B. Hypokalemia ✅
C. Hypocalcemia
D. HypermagnesemiaA client reports abdominal pain and vomiting. Which finding requires immediate intervention?
A. Bowel sounds present in all quadrants
B. Soft, non-tender abdomen
C. Hematemesis ✅
D. Nausea after mealsWhich is an expected finding in a client with right-sided heart failure?
A. Pulmonary congestion
B. Pink frothy sputum
C. Peripheral edema ✅
D. OrthopneaWhich position promotes drainage from a lobectomy site in the right lung?
A. Left side-lying ✅
B. Supine
C. Right side-lying
D. High Fowler’sWhat is an adverse effect of levothyroxine?
A. Constipation
B. Bradycardia
C. Insomnia ✅
D. Weight gainWhich of the following foods should a client taking MAOIs avoid?
A. Yogurt
B. Cottage cheese
C. Aged cheddar ✅
D. MilkA client with COPD is receiving oxygen therapy. Which oxygen delivery device is most appropriate for long-term use?
A. Non-rebreather mask
B. Simple face mask
C. Nasal cannula ✅
D. Venturi maskWhich lab value should a nurse monitor for a client receiving heparin therapy?
A. INR
B. Platelet count
C. aPTT ✅
D. HemoglobinWhich is a common side effect of opioid analgesics?
A. Diarrhea
B. Insomnia
C. Constipation ✅
D. HypertensionWhat is the priority action when a client experiences an anaphylactic reaction to a medication?
A. Start IV fluids
B. Give diphenhydramine
C. Administer epinephrine ✅
D. Provide emotional supportA client is prescribed lithium. Which of the following should be reported to the provider?
A. Weight gain
B. Fine hand tremor
C. Polyuria
D. Vomiting and diarrhea ✅Which assessment finding is expected in a client with left-sided heart failure?
A. Jugular vein distension
B. Crackles in the lungs ✅
C. Hepatomegaly
D. Peripheral edemaWhich of the following indicates digoxin toxicity?
A. Hypertension
B. Yellow-tinged vision ✅
C. Increased appetite
D. TachycardiaWhat is the purpose of incentive spirometry?
A. Increase oxygen saturation
B. Promote alveolar expansion ✅
C. Reduce mucus production
D. Treat bronchospasmsWhat dietary recommendation is appropriate for a client with celiac disease?
A. Low fat
B. High fiber
C. Gluten-free ✅
D. High proteinWhich of the following is a manifestation of hyperthyroidism?
A. Cold intolerance
B. Weight gain
C. Tachycardia ✅
D. ConstipationA client with a spinal cord injury at T6 is at risk for which complication?
A. Autonomic dysreflexia ✅
B. Pulmonary embolism
C. Cardiac tamponade
D. Diabetic ketoacidosisWhich of the following lab values is consistent with renal failure?
A. Decreased creatinine
B. Decreased BUN
C. Increased potassium ✅
D. Increased calciumWhich is a priority intervention for a client with a suspected stroke?
A. Monitor blood glucose
B. Assess swallowing
C. Maintain airway patency ✅
D. Apply oxygenWhich condition is treated with levodopa-carbidopa?
A. Seizures
B. Parkinson’s disease ✅
C. Schizophrenia
D. Multiple sclerosisWhich finding is expected in a client with diabetes insipidus?
A. Oliguria
B. Low serum sodium
C. High urine output ✅
D. EdemaWhat teaching is important for a client taking alendronate?
A. Take with food
B. Lie down after taking
C. Take with full glass of water and remain upright ✅
D. Take at bedtimeWhich of the following vaccines is safe during pregnancy?
A. MMR
B. Varicella
C. Influenza (inactivated) ✅
D. HPVWhat is a common symptom of meningitis in adults?
A. Tachycardia
B. Photophobia ✅
C. Nausea
D. VomitingWhich of the following is a contraindication to thrombolytic therapy?
A. History of hypertension
B. Recent surgery ✅
C. Diabetes
D. Atrial fibrillationWhich lab value is most important to monitor in a client receiving enoxaparin?
A. aPTT
B. INR
C. Platelet count ✅
D. SodiumWhich is an appropriate nursing action for a client with neutropenia?
A. Encourage fresh fruits and vegetables
B. Place in negative pressure room
C. Restrict visitors with infections ✅
D. Provide humidified oxygenWhat is a manifestation of hypocalcemia?
A. Constipation
B. Muscle twitching ✅
C. Lethargy
D. BradycardiaA client with a new tracheostomy has thick secretions. What is the nurse’s priority action?
A. Encourage oral fluids
B. Increase humidification ✅
C. Suction frequently
D. Give antibioticsWhich is a priority intervention for a client with major depressive disorder?
A. Encourage group therapy
B. Monitor for suicidal ideation ✅
C. Provide high-calorie snacks
D. Promote independenceWhat is a risk factor for cataracts?
A. Obesity
B. Smoking ✅
C. High cholesterol
D. HyperthyroidismWhich insulin has the fastest onset?
A. NPH
B. Regular
C. Glargine
D. Lispro ✅A client has a potassium level of 6.0 mEq/L. What is the priority action?
A. Restrict fluids
B. Administer potassium chloride
C. Place on cardiac monitor ✅
D. Provide high-potassium dietWhich is a manifestation of increased intracranial pressure?
A. Bradycardia ✅
B. Tachycardia
C. Hypotension
D. Pupil constrictionWhat teaching should be given to a client using an inhaled corticosteroid?
A. Use before bronchodilator
B. Rinse mouth after use ✅
C. Take with food
D. Avoid shaking the inhaler
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