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NR302 Exam 3

Question 1

The nurse is planning to assess an older adult’s peripheral vision using the confrontation test. Which action should the nurse include to ensure accurate testing?

1. Instruct the client to keep both eyes open.
2. Stand directly behind the client during the assessment.

✓ C. Stand at eye level facing the client during the assessment.

1. Hold a stationary object in the center of vision.

Question 2

What should the nurse feel when placing their hands on the posterior lateral chest during a deep breath?

 

1. Asymmetrical rise and fall of the rib cage

 

1. No movement of the rib cage

 

1. Pain during chest expansion

 

✅ D. Symmetrical rise and fall of the rib cage

 

Question 3

A nurse is preparing to give an I-SBAR report after completing a head-to-chest assessment. Which statement should the nurse include in the Assessment section of the report?

 

✅ A. “The client is alert and oriented, speech is clear, and lung sounds are clear bilaterally.”

 

1. “I am Susan, the nurse assigned to complete the client’s assessment.”

 

1. “The client tolerated the assessment, and the call light is within reach.”

 

1. “The client is Annie Laduke, and the assessment took about 20 minutes.”

 

Question 4

Which inspection finding likely indicates atelectasis in a postoperative adult client?

 

1. Cyanosis of lips and nailbeds

 

1. Barrel-shaped chest with widened costal angle

 

1. Bilaterally symmetric chest movement with quiet respirations

 

✅ D. Intercostal retractions on affected side during inspiration

 

Question 5

A nurse is assigning client care to an unlicensed assistive personnel (UAP). Which client should be assigned to the UAP?

 

1. A client requiring straight catheterization for a urine specimen.

 

1. A client who requires teaching about new prescription medications.

 

✅ C. A client who requires assistance with bathing and hygiene care.

 

1. A client receiving IV antibiotics who needs monitoring for complications.

 

Question 6

A nurse is preparing to assess a client using a stethoscope. Which action is most effective in preventing infection transmission between clients?

 

1. Clean off the client’s bedside table.

 

✅ B. Disinfect the stethoscope before use.

 

1. Change the stethoscope earpieces regularly.

 

1. Don clean gloves during the assessment.

 

Question 7

A nurse is completing skin assessments on several clients. Which client should the nurse assess first?

 

1. A client with symmetric mole measuring 3 mm with uniform brown color.

 

1. A client with a light brown freckle on the left arm that has remained unchanged.

 

1. A client with multiple small similar-appearing nevi across the arms and back.

 

✅ D. A client with a 7 mm mole that has recently changed in size and is itching.

Question 8

A nurse notes high-pitched, loud lung sounds over the trachea. How should the nurse document this finding?

1. Bronchial breath sounds clear, no adventitious sounds noted

✓ B. Tracheal breath sounds clear and even bilaterally

1. Adventitious stridor auscultated over the upper airway
2. Vesicular breath sounds clear in bilateral lung apices

Question 9

A nurse identifies enlarged lymph nodes in the submandibular region. Which assessment should the nurse perform?

1. Inspect the lower extremities for signs of infection.
2. Palpate the inguinal region for lymph node enlargement.

✓ C. Examine the oral cavity and surrounding facial structures.

1. Assess lung sounds in the upper posterior chest.

Question 10

When inspecting and palpating the external ear, which technique should the nurse use to assess tenderness?

1. Inspect the external ear for redness, swelling, and lesions.

✓ B. Move the pinna, push on the tragus, and palpate the mastoid process.

1. Insert the otoscope speculum and rotate it firmly in the canal.
2. Pull the earlobe downward and ask the client to swallow twice.

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