NURS 302 ASSESSMENT 2 QUESTIONS AND ANSWERS | LATEST NURS
302 STUDY GUIDE & PRACTICE TEST 2026/2027
After assessing the client and identifying the need for
pain relief, the nurse administers an analgesic. What is the
next priority nursing action for this client? - ANS ✔✔EVALUATE: check respiratory rate
Which of the following is a client-centered outcome
for a patient experiencing acute pain?
a.The nurse will administer ordered pain med q4 hrs
b.Staff will respond to pt's call bell within 5 minutes and measure / record vital signs.
c. Client will report a decreased pain level of 2/10 within 30 minutes after pain med administration.
d.Client will be discharged to home on no pain medications. - ANS ✔✔c. Client will report a decreased
pain level of 2/10 within 30 minutes after pain med administration
The nurse is caring for a client who had abdominal surgery 3 days ago. The client is reluctant to
ambulate, or move around much. Client states they prefer to stay in bed and rest.
Upon assessment, the nurse notes that the surgical incision is well approximated, with no s/s of
Infection.
Vital Signs: T 100.8* F (O), P=88, R=20, shallow, BP=118/78, O2 sat =92% RA
Auscultating the patient's lung fields, the nurse notes crackles at the bases.
Priority Nursing Action? - ANS ✔✔Assist to ambulate, Cough & Deep Breath; incentive spirometer
Which are signs/symptoms of FLUID OVERLOAD? (SATA)
A. Dark colored urine
B. Hypotension
C. Pitting edema in the feet
D. Dry mucus membranes
E. Tachycardia
F. Weight gain of 4 lbs in 24 hrs
G. Bounding Pulse
H. Hypertension
I.Tachypnea
J. Head Ache - ANS ✔✔C. Pitting edema in the feet
E. Tachycardia
F. Weight gain of 4 lbs in 24 hrs
G. Bounding Pulse
H. Hypertension
I.Tachypnea
,J. Head Ache
A,B,D = fluid underload
Definition of ORTHOPNEA, and what it indicates.
Nursing Intervention. - ANS ✔✔"Straight breathing," or "Straight-Up Breathing."
intervention: elevate H.O.B.> semifowlers
If a person is HYPERVENTILATING, they may experience symptoms
of numbness, tingling, and potential loss of consciousness.
These symptoms are caused by:
a.Hypocapnea
b.Hypoxia
c.Hyperoxia
d.Anoxia
e.Hyperkalemia - ANS ✔✔hypocapnea
early signs and symptoms of hypoxia - ANS ✔✔restlessness, agitation, irritability, possibly tachypnea,
Decreased l.o.c.
The nurse notes that their patient's H&H is 27% Hct and Hgb=8.8. This result may indicate that the
patient will have:
a.Hypovolemia
b.Hypoxia
c.Increased lung compliance
d.Crackles at the bases - ANS ✔✔hypoxia
the client's hemoglobin is 6.9g/dL
and the hematocrit is 20%.
Would oxygen supplementation be beneficial here? - ANS ✔✔yes. O2 at 2-4 L/min Nasal cannula
If a client has a simple oxygen mask, the liter flow should be:
a.2-4 L/min
b.4-8 L/min
c.6-12 L/min
d.15 L/min - ANS ✔✔6-12 L/min
What are phenomena,
signs & symptoms of left-side heart failure? - ANS ✔✔decreased cardiac output
moist lung sounds
Signs & symptoms of right-side heart failure? - ANS ✔✔+JVD w/h.o.b. elevated at 45*
Dependent edema
, Lab test /results to evaluate heart failure? - ANS ✔✔BNP >100pg/mL
normal albumin levels - ANS ✔✔3.5-5.0 g/dL
normal Serum potassium level - ANS ✔✔3.5-5 mmol/L
a nurse is developing a plan for a patient who was diagnosed with narcolepsy. which interventions
should the nurse include on the plan? (SATA)
a. take brief, 20 min naps no more than twice a day
b. drink a glass of wine with dinner
c. eat a large meal at lunch rather than dinner
d. establish a regular exercise program
e. teach the patient about the side effects of modafinil - ANS ✔✔a, d, e
a. take brief, 20 min naps no more than twice a day
d. establish a regular exercise program
e. teach the patient about the side effects of modafinil (medication used to treat narcolepsy)
which statements from a patient indicate an understanding of behaviors that will promote sleep? (SATA)
a. "I will not watch television in bed"
b. "I will not drink caffeine later in the day"
c. "a short nap late in the evening will lead to a more restful night of sleep"
d. "I am going to start eating dinner close to my bedtime"
e. "I will start to exercise regularly during the day" - ANS ✔✔a, b, e
a 72-year old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to
help her get to sleep.
what is the nurse's best response?
a. antihistamines are better than prescription medications because prescription medications can cause a
lot of problems
b. antihistamines should not be used because they can cause confusion and increase your risk for falls
c. antihistamines are effective sleep aids because they do not have many side effects
d. over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep
- ANS ✔✔b. antihistamines should not be used because they can cause confusion and increase your risk
for falls
which nursing intervention(s) best promote(s) effective sleep in an older adult? (SATA)
a. limit fluids 2-4 hours before sleep
b. ensure that the room is completely dark
c. ensure that the room temperature is comfortably cool
d. provide warm covers
e. encourage walking an hour before going to bed - ANS ✔✔a. limit fluids 2-4 hours before sleep
c. ensure that the room temperature is comfortably cool
d. provide warm covers
which statement made by the patient indicates an understanding of sleep-hygiene practices?
a. "I usually drink a cup of warm milk in the evening to help me sleep"
302 STUDY GUIDE & PRACTICE TEST 2026/2027
After assessing the client and identifying the need for
pain relief, the nurse administers an analgesic. What is the
next priority nursing action for this client? - ANS ✔✔EVALUATE: check respiratory rate
Which of the following is a client-centered outcome
for a patient experiencing acute pain?
a.The nurse will administer ordered pain med q4 hrs
b.Staff will respond to pt's call bell within 5 minutes and measure / record vital signs.
c. Client will report a decreased pain level of 2/10 within 30 minutes after pain med administration.
d.Client will be discharged to home on no pain medications. - ANS ✔✔c. Client will report a decreased
pain level of 2/10 within 30 minutes after pain med administration
The nurse is caring for a client who had abdominal surgery 3 days ago. The client is reluctant to
ambulate, or move around much. Client states they prefer to stay in bed and rest.
Upon assessment, the nurse notes that the surgical incision is well approximated, with no s/s of
Infection.
Vital Signs: T 100.8* F (O), P=88, R=20, shallow, BP=118/78, O2 sat =92% RA
Auscultating the patient's lung fields, the nurse notes crackles at the bases.
Priority Nursing Action? - ANS ✔✔Assist to ambulate, Cough & Deep Breath; incentive spirometer
Which are signs/symptoms of FLUID OVERLOAD? (SATA)
A. Dark colored urine
B. Hypotension
C. Pitting edema in the feet
D. Dry mucus membranes
E. Tachycardia
F. Weight gain of 4 lbs in 24 hrs
G. Bounding Pulse
H. Hypertension
I.Tachypnea
J. Head Ache - ANS ✔✔C. Pitting edema in the feet
E. Tachycardia
F. Weight gain of 4 lbs in 24 hrs
G. Bounding Pulse
H. Hypertension
I.Tachypnea
,J. Head Ache
A,B,D = fluid underload
Definition of ORTHOPNEA, and what it indicates.
Nursing Intervention. - ANS ✔✔"Straight breathing," or "Straight-Up Breathing."
intervention: elevate H.O.B.> semifowlers
If a person is HYPERVENTILATING, they may experience symptoms
of numbness, tingling, and potential loss of consciousness.
These symptoms are caused by:
a.Hypocapnea
b.Hypoxia
c.Hyperoxia
d.Anoxia
e.Hyperkalemia - ANS ✔✔hypocapnea
early signs and symptoms of hypoxia - ANS ✔✔restlessness, agitation, irritability, possibly tachypnea,
Decreased l.o.c.
The nurse notes that their patient's H&H is 27% Hct and Hgb=8.8. This result may indicate that the
patient will have:
a.Hypovolemia
b.Hypoxia
c.Increased lung compliance
d.Crackles at the bases - ANS ✔✔hypoxia
the client's hemoglobin is 6.9g/dL
and the hematocrit is 20%.
Would oxygen supplementation be beneficial here? - ANS ✔✔yes. O2 at 2-4 L/min Nasal cannula
If a client has a simple oxygen mask, the liter flow should be:
a.2-4 L/min
b.4-8 L/min
c.6-12 L/min
d.15 L/min - ANS ✔✔6-12 L/min
What are phenomena,
signs & symptoms of left-side heart failure? - ANS ✔✔decreased cardiac output
moist lung sounds
Signs & symptoms of right-side heart failure? - ANS ✔✔+JVD w/h.o.b. elevated at 45*
Dependent edema
, Lab test /results to evaluate heart failure? - ANS ✔✔BNP >100pg/mL
normal albumin levels - ANS ✔✔3.5-5.0 g/dL
normal Serum potassium level - ANS ✔✔3.5-5 mmol/L
a nurse is developing a plan for a patient who was diagnosed with narcolepsy. which interventions
should the nurse include on the plan? (SATA)
a. take brief, 20 min naps no more than twice a day
b. drink a glass of wine with dinner
c. eat a large meal at lunch rather than dinner
d. establish a regular exercise program
e. teach the patient about the side effects of modafinil - ANS ✔✔a, d, e
a. take brief, 20 min naps no more than twice a day
d. establish a regular exercise program
e. teach the patient about the side effects of modafinil (medication used to treat narcolepsy)
which statements from a patient indicate an understanding of behaviors that will promote sleep? (SATA)
a. "I will not watch television in bed"
b. "I will not drink caffeine later in the day"
c. "a short nap late in the evening will lead to a more restful night of sleep"
d. "I am going to start eating dinner close to my bedtime"
e. "I will start to exercise regularly during the day" - ANS ✔✔a, b, e
a 72-year old patient asks the nurse about using an over-the-counter antihistamine as a sleeping pill to
help her get to sleep.
what is the nurse's best response?
a. antihistamines are better than prescription medications because prescription medications can cause a
lot of problems
b. antihistamines should not be used because they can cause confusion and increase your risk for falls
c. antihistamines are effective sleep aids because they do not have many side effects
d. over-the-counter medications when combined with sleep-hygiene measures are a good plan for sleep
- ANS ✔✔b. antihistamines should not be used because they can cause confusion and increase your risk
for falls
which nursing intervention(s) best promote(s) effective sleep in an older adult? (SATA)
a. limit fluids 2-4 hours before sleep
b. ensure that the room is completely dark
c. ensure that the room temperature is comfortably cool
d. provide warm covers
e. encourage walking an hour before going to bed - ANS ✔✔a. limit fluids 2-4 hours before sleep
c. ensure that the room temperature is comfortably cool
d. provide warm covers
which statement made by the patient indicates an understanding of sleep-hygiene practices?
a. "I usually drink a cup of warm milk in the evening to help me sleep"
