NR 302 Health Assessment | Exam 2 Total: 120 Questions
NR302 / NR 302: HEALTH ASSESSMENT
EXAM 2 (LATEST )
CHAMBERLAIN COLLEGE OF NURSING
Comprehensive Examination | Aligned with the Chamberlain University NR 302 Course Syllabus, the NCLEX-RN Test Plan,
QSEN Competencies, and Health Assessment Standards (2026/2027 Edition)
120 Multiple-Choice Questions | Correct Answers and Rationales Included | Cognitive Mix: 20% Recall, 50% Application, 30%
Analysis
Section 1: General Survey, Vital Signs, & Pain Assessment (Questions 1-12)
Q1. The nurse enters a medical unit patient's room to begin the shift assessment. Which observation made during
the general survey should the nurse address first?
A. The patient's hair is uncombed and the gown is wrinkled
B. The patient appears dusky and is using neck muscles to breathe [CORRECT]
C. The patient is watching television with a family member
D. The patient's water pitcher is half full on the overbed table
Correct Answer: B
Rationale: The general survey is a study of the whole person that begins the moment the nurse encounters the patient,
covering appearance, body structure, behavior, and immediate distress. Dusky color with accessory muscle use signals
compromised oxygenation, an ABC-priority finding that requires immediate intervention. Hygiene, activity level, and
environmental observations are documented but are not life-threatening.
Q2. Which assessment finding should the nurse document under the 'behavior' component of the general survey?
A. Body parts appear symmetrical with no deformities
B. Height appears proportionate to body build
C. Speech is clear, coherent, and organized [CORRECT]
D. Skin color is consistent across body surfaces
Correct Answer: C
Rationale: The behavior portion of the general survey includes level of consciousness, facial expression, speech pattern,
mood and affect, and personal interaction. Clear, coherent, organized speech is a behavior finding. Symmetry and
proportion describe body structure, while consistent skin color describes physical appearance.
1
,NR 302 Health Assessment | Exam 2 Total: 120 Questions
Q3. An older adult reports lightheadedness every time he gets out of bed. Which technique should the nurse use
to correctly assess for orthostatic hypotension?
A. Measure blood pressure and heart rate with the patient supine, then repeat 1 and 3 minutes after standing
[CORRECT]
B. Compare blood pressure readings taken on the left and right arms while the patient sits
C. Have the patient walk rapidly in the hallway for 2 minutes and measure blood pressure immediately
afterward
D. Measure blood pressure with the patient sitting and again exactly 10 seconds after standing
Correct Answer: A
Rationale: Orthostatic (postural) vital signs require a supine baseline, then repeat measurements at 1 and 3 minutes of
standing; a drop in systolic pressure of at least 20 mm Hg or diastolic of at least 10 mm Hg confirms orthostatic
hypotension. Arm-to-arm comparison evaluates circulation differences, not postural response, and a 10-second interval
is far too brief to capture the delayed pressure drop.
Q4. The nurse measures the blood pressure of an adult with an obese upper arm using a cuff that is too narrow
for the extremity. Which result should the nurse anticipate?
A. Falsely low systolic and diastolic values
B. No clinically significant change in the reading
C. Falsely low diastolic value with accurate systolic value
D. Falsely high systolic and diastolic values [CORRECT]
Correct Answer: D
Rationale: A cuff that is too narrow (or too short) must be inflated to a higher pressure to occlude the brachial artery,
producing falsely elevated readings; the bladder should cover roughly 40% of arm circumference and 80% of arm
length. An oversized cuff produces the opposite error, falsely low values, which is why cuff selection is validated before
every measurement.
Q5. The nurse is using the PQRST method to assess a patient's chest pain. Which question should the nurse ask
to evaluate the 'T' in PQRST?
A. What makes the pain better or worse?
B. Can you describe what the pain feels like?
C. How long does the pain last, and when did it begin? [CORRECT]
D. Does the pain travel anywhere else in your body?
Correct Answer: C
Rationale: In PQRST, T represents timing, including onset, duration, and frequency of the pain episode. Questions
about aggravating or relieving factors assess P (provocation and palliation), quality descriptors assess Q, and radiation
assesses R. Severity, the S, is measured with a 0-to-10 intensity scale.
2
,NR 302 Health Assessment | Exam 2 Total: 120 Questions
Q6. A nurse needs to assess pain in an 84-year-old patient with advanced Alzheimer disease who is unable to
self-report. Which pain assessment tool is most appropriate?
A. PAINAD (Pain Assessment in Advanced Dementia) scale [CORRECT]
B. Numeric rating scale from 0 to 10
C. Wong-Baker FACES Pain Rating Scale
D. Visual analog scale
Correct Answer: A
Rationale: The PAINAD scale is validated for patients with advanced dementia who cannot self-report; it scores
breathing, vocalization, facial expression, body language, and consolability. The numeric scale, FACES scale, and visual
analog scale all require the patient to actively indicate a self-reported rating, which is impossible in advanced dementia.
Q7. A 2-year-old is 6 hours postoperative and cannot verbalize pain intensity. The nurse notes the child is crying
inconsolably, kicking, and lying with the body arched and rigid. Which pain scale should the nurse use?
A. Numeric rating scale from 0 to 10
B. FLACC behavioral scale [CORRECT]
C. OLDCARTS mnemonic
D. PAINAD scale
Correct Answer: B
Rationale: The FLACC scale (Faces, Legs, Activity, Cry, Consolability) is a validated behavioral instrument for
children 2 months to 7 years and for any nonverbal patient; this child's crying, leg movement, and arched position are
directly scoreable. The numeric scale requires self-report, OLDCARTS is a symptom-history mnemonic rather than an
observational scale, and PAINAD is designed for dementia in older adults.
Q8. For which patient is the Wong-Baker FACES Pain Rating Scale most appropriate?
A. A 4-year-old who can point to pictures [CORRECT]
B. A 6-month-old infant who is crying
C. A 90-year-old with advanced cognitive impairment
D. A 2-day-old newborn in the nursery
Correct Answer: A
Rationale: The Wong-Baker FACES scale is appropriate for children approximately 3 years and older because the child
selects the face that best matches the felt pain; a 4-year-old can point to a picture. Infants and newborns require
behavioral scales such as FLACC, and patients with advanced cognitive impairment require an observational tool such as
PAINAD.
Q9. A patient states he finished drinking a cup of hot coffee 5 minutes ago, and the nurse needs to obtain an oral
temperature. Which action is most appropriate?
A. Measure the temperature now and document that coffee was recently consumed
B. Have the patient rinse the mouth with cold water and measure the temperature immediately
C. Obtain an axillary temperature within the next 2 minutes
D. Wait 15 to 30 minutes before measuring the oral temperature [CORRECT]
3
, NR 302 Health Assessment | Exam 2 Total: 120 Questions
Correct Answer: D
Rationale: Hot or cold liquids and smoking alter oral mucosal temperature for approximately 15 to 30 minutes, so the
nurse delays oral measurement to obtain an accurate baseline value. Measuring immediately records a falsely elevated
temperature, a brief rinse does not restore true mucosal temperature, and the axillary route should not be used hastily
because it is the least accurate route and reflects core temperature poorly.
Q10. Which technique should the nurse use to obtain an accurate respiratory rate on an alert adult patient?
A. Announce that you are counting breaths so the patient can breathe naturally
B. Count respirations while the patient is speaking in full sentences
C. After counting the radial pulse, keep the fingers on the wrist and inconspicuously count chest excursions
for 30 seconds and multiply by 2 [CORRECT]
D. Ask the patient to take deep breaths while you observe the chest
Correct Answer: C
Rationale: Patients unconsciously alter their breathing pattern once they know it is being observed, so the nurse counts
respirations immediately after the pulse count while the fingers remain on the wrist, appearing to continue taking the
pulse. A 30-second count multiplied by 2 is acceptable when the pattern is regular (a full minute is used if irregular).
Announcing the count, counting during speech, and requesting deep breathing all distort the resting respiratory pattern.
Q11. A patient with low back pain states, 'The pain never completely goes away, although some days are better
than others. I have had it for over a year.' Vital signs are within normal limits. Which classification of pain
should the nurse document?
A. Acute nociceptive pain
B. Chronic persistent (nonmalignant) pain [CORRECT]
C. Referred pain
D. Phantom pain
Correct Answer: B
Rationale: Pain persisting beyond the expected healing time, typically more than 3 to 6 months, is chronic persistent
pain; because the autonomic nervous system adapts, vital signs are often normal despite significant suffering. Acute pain
is recent with sympathetic activation (elevated pulse, blood pressure), referred pain is felt at a site distant from its origin,
and phantom pain occurs in an amputated body part.
Q12. A nurse notes an SpO2 of 88% displayed on a patient who has warm, pink hands, no nail polish on two
nails, and no complaints of dyspnea. What should the nurse do first?
A. Apply 100% oxygen via nonrebreather mask and notify the provider
B. Document 88% as the patient's baseline oxygen saturation
C. Raise the pulse oximeter alarm limits to prevent repeated alarms
D. Remove any nail polish, reposition the probe, and recheck the reading [CORRECT]
4
NR302 / NR 302: HEALTH ASSESSMENT
EXAM 2 (LATEST )
CHAMBERLAIN COLLEGE OF NURSING
Comprehensive Examination | Aligned with the Chamberlain University NR 302 Course Syllabus, the NCLEX-RN Test Plan,
QSEN Competencies, and Health Assessment Standards (2026/2027 Edition)
120 Multiple-Choice Questions | Correct Answers and Rationales Included | Cognitive Mix: 20% Recall, 50% Application, 30%
Analysis
Section 1: General Survey, Vital Signs, & Pain Assessment (Questions 1-12)
Q1. The nurse enters a medical unit patient's room to begin the shift assessment. Which observation made during
the general survey should the nurse address first?
A. The patient's hair is uncombed and the gown is wrinkled
B. The patient appears dusky and is using neck muscles to breathe [CORRECT]
C. The patient is watching television with a family member
D. The patient's water pitcher is half full on the overbed table
Correct Answer: B
Rationale: The general survey is a study of the whole person that begins the moment the nurse encounters the patient,
covering appearance, body structure, behavior, and immediate distress. Dusky color with accessory muscle use signals
compromised oxygenation, an ABC-priority finding that requires immediate intervention. Hygiene, activity level, and
environmental observations are documented but are not life-threatening.
Q2. Which assessment finding should the nurse document under the 'behavior' component of the general survey?
A. Body parts appear symmetrical with no deformities
B. Height appears proportionate to body build
C. Speech is clear, coherent, and organized [CORRECT]
D. Skin color is consistent across body surfaces
Correct Answer: C
Rationale: The behavior portion of the general survey includes level of consciousness, facial expression, speech pattern,
mood and affect, and personal interaction. Clear, coherent, organized speech is a behavior finding. Symmetry and
proportion describe body structure, while consistent skin color describes physical appearance.
1
,NR 302 Health Assessment | Exam 2 Total: 120 Questions
Q3. An older adult reports lightheadedness every time he gets out of bed. Which technique should the nurse use
to correctly assess for orthostatic hypotension?
A. Measure blood pressure and heart rate with the patient supine, then repeat 1 and 3 minutes after standing
[CORRECT]
B. Compare blood pressure readings taken on the left and right arms while the patient sits
C. Have the patient walk rapidly in the hallway for 2 minutes and measure blood pressure immediately
afterward
D. Measure blood pressure with the patient sitting and again exactly 10 seconds after standing
Correct Answer: A
Rationale: Orthostatic (postural) vital signs require a supine baseline, then repeat measurements at 1 and 3 minutes of
standing; a drop in systolic pressure of at least 20 mm Hg or diastolic of at least 10 mm Hg confirms orthostatic
hypotension. Arm-to-arm comparison evaluates circulation differences, not postural response, and a 10-second interval
is far too brief to capture the delayed pressure drop.
Q4. The nurse measures the blood pressure of an adult with an obese upper arm using a cuff that is too narrow
for the extremity. Which result should the nurse anticipate?
A. Falsely low systolic and diastolic values
B. No clinically significant change in the reading
C. Falsely low diastolic value with accurate systolic value
D. Falsely high systolic and diastolic values [CORRECT]
Correct Answer: D
Rationale: A cuff that is too narrow (or too short) must be inflated to a higher pressure to occlude the brachial artery,
producing falsely elevated readings; the bladder should cover roughly 40% of arm circumference and 80% of arm
length. An oversized cuff produces the opposite error, falsely low values, which is why cuff selection is validated before
every measurement.
Q5. The nurse is using the PQRST method to assess a patient's chest pain. Which question should the nurse ask
to evaluate the 'T' in PQRST?
A. What makes the pain better or worse?
B. Can you describe what the pain feels like?
C. How long does the pain last, and when did it begin? [CORRECT]
D. Does the pain travel anywhere else in your body?
Correct Answer: C
Rationale: In PQRST, T represents timing, including onset, duration, and frequency of the pain episode. Questions
about aggravating or relieving factors assess P (provocation and palliation), quality descriptors assess Q, and radiation
assesses R. Severity, the S, is measured with a 0-to-10 intensity scale.
2
,NR 302 Health Assessment | Exam 2 Total: 120 Questions
Q6. A nurse needs to assess pain in an 84-year-old patient with advanced Alzheimer disease who is unable to
self-report. Which pain assessment tool is most appropriate?
A. PAINAD (Pain Assessment in Advanced Dementia) scale [CORRECT]
B. Numeric rating scale from 0 to 10
C. Wong-Baker FACES Pain Rating Scale
D. Visual analog scale
Correct Answer: A
Rationale: The PAINAD scale is validated for patients with advanced dementia who cannot self-report; it scores
breathing, vocalization, facial expression, body language, and consolability. The numeric scale, FACES scale, and visual
analog scale all require the patient to actively indicate a self-reported rating, which is impossible in advanced dementia.
Q7. A 2-year-old is 6 hours postoperative and cannot verbalize pain intensity. The nurse notes the child is crying
inconsolably, kicking, and lying with the body arched and rigid. Which pain scale should the nurse use?
A. Numeric rating scale from 0 to 10
B. FLACC behavioral scale [CORRECT]
C. OLDCARTS mnemonic
D. PAINAD scale
Correct Answer: B
Rationale: The FLACC scale (Faces, Legs, Activity, Cry, Consolability) is a validated behavioral instrument for
children 2 months to 7 years and for any nonverbal patient; this child's crying, leg movement, and arched position are
directly scoreable. The numeric scale requires self-report, OLDCARTS is a symptom-history mnemonic rather than an
observational scale, and PAINAD is designed for dementia in older adults.
Q8. For which patient is the Wong-Baker FACES Pain Rating Scale most appropriate?
A. A 4-year-old who can point to pictures [CORRECT]
B. A 6-month-old infant who is crying
C. A 90-year-old with advanced cognitive impairment
D. A 2-day-old newborn in the nursery
Correct Answer: A
Rationale: The Wong-Baker FACES scale is appropriate for children approximately 3 years and older because the child
selects the face that best matches the felt pain; a 4-year-old can point to a picture. Infants and newborns require
behavioral scales such as FLACC, and patients with advanced cognitive impairment require an observational tool such as
PAINAD.
Q9. A patient states he finished drinking a cup of hot coffee 5 minutes ago, and the nurse needs to obtain an oral
temperature. Which action is most appropriate?
A. Measure the temperature now and document that coffee was recently consumed
B. Have the patient rinse the mouth with cold water and measure the temperature immediately
C. Obtain an axillary temperature within the next 2 minutes
D. Wait 15 to 30 minutes before measuring the oral temperature [CORRECT]
3
, NR 302 Health Assessment | Exam 2 Total: 120 Questions
Correct Answer: D
Rationale: Hot or cold liquids and smoking alter oral mucosal temperature for approximately 15 to 30 minutes, so the
nurse delays oral measurement to obtain an accurate baseline value. Measuring immediately records a falsely elevated
temperature, a brief rinse does not restore true mucosal temperature, and the axillary route should not be used hastily
because it is the least accurate route and reflects core temperature poorly.
Q10. Which technique should the nurse use to obtain an accurate respiratory rate on an alert adult patient?
A. Announce that you are counting breaths so the patient can breathe naturally
B. Count respirations while the patient is speaking in full sentences
C. After counting the radial pulse, keep the fingers on the wrist and inconspicuously count chest excursions
for 30 seconds and multiply by 2 [CORRECT]
D. Ask the patient to take deep breaths while you observe the chest
Correct Answer: C
Rationale: Patients unconsciously alter their breathing pattern once they know it is being observed, so the nurse counts
respirations immediately after the pulse count while the fingers remain on the wrist, appearing to continue taking the
pulse. A 30-second count multiplied by 2 is acceptable when the pattern is regular (a full minute is used if irregular).
Announcing the count, counting during speech, and requesting deep breathing all distort the resting respiratory pattern.
Q11. A patient with low back pain states, 'The pain never completely goes away, although some days are better
than others. I have had it for over a year.' Vital signs are within normal limits. Which classification of pain
should the nurse document?
A. Acute nociceptive pain
B. Chronic persistent (nonmalignant) pain [CORRECT]
C. Referred pain
D. Phantom pain
Correct Answer: B
Rationale: Pain persisting beyond the expected healing time, typically more than 3 to 6 months, is chronic persistent
pain; because the autonomic nervous system adapts, vital signs are often normal despite significant suffering. Acute pain
is recent with sympathetic activation (elevated pulse, blood pressure), referred pain is felt at a site distant from its origin,
and phantom pain occurs in an amputated body part.
Q12. A nurse notes an SpO2 of 88% displayed on a patient who has warm, pink hands, no nail polish on two
nails, and no complaints of dyspnea. What should the nurse do first?
A. Apply 100% oxygen via nonrebreather mask and notify the provider
B. Document 88% as the patient's baseline oxygen saturation
C. Raise the pulse oximeter alarm limits to prevent repeated alarms
D. Remove any nail polish, reposition the probe, and recheck the reading [CORRECT]
4
