Nurs 225 Final Exam Questions and
Complete Solutions
The registered nurse (RN) is observing a nursing student auscultate the patient's breath
sounds. The RN intervenes if the nursing student performs which action?
a)Asks the patient to sit straight up
b)Instructs the patient to breathe slowly and deeply though the mouth
c)Places the stethoscope directly on the patient's skin
d)Uses the bell of the stethoscope ✅d
Which of the following would reflect an abnormality in cranial nerve III?
a)Gag reflex is absent and dysphagia is noted
b)Hearing loss is identified on the right side
c)The left pupil of the patient fails to accommodate
d)The patient is unable to chew or bite down ✅c
Which of the following is an example of an active listening behavior?
a)Taking frequent notes
b)Asking for more details
c)Leaning toward the patient
d)Sitting comfortably with legs crossed ✅c
The nurse is planning the care of a frail, immobile, elderly patient. Which of the following
is the best treatment or prevention to protect the patient's skin?
a)Administer fluid boluses as directed by the healthcare provider
b)Assisting the patient to sit in a chair three times a day
c)Offering the patient six small meals a day
d)Turning the patient at least every 2 hours ✅d
A nurse is performing an otoscopic examination of a client. Which of the following is an
unexpected finding?
a)Pearly, gray tympanic membrane (TM)
b)Malleous visible behind the TM
c)Flaky skin in the external canal near the TM
d)Black cerumen partially occluding the TM ✅d
A nurse is completing an assessment of a client who is a first generation immigrant to
the U.S. Which of the following questions should the nurse consider asking to
understand the client's culture-based nutrition habits?
a)"What type of afternoon snacks do you consume?"
b)"What type of meal do you prepare for a holiday?"
c)"What time of day do you eat breakfast?"
d)"What cooking utensils are used in food preparation?" ✅b
,A nurse is assessing a client who is in respiratory distress. The nurse should recognize
that which of the following can cause a low pulse oximetry reading? (select all that
apply)
a) nail polish
b) inadequate peripheral circualtion
c) hyperthermia
d) increased hgb level
e)edema ✅a,b,e
Which statement related to prioritizing patient problems is most accurate?
a)Nurses must resolve one problem before addressing another problem.
b)Nurses prioritize problems in order of urgency.
c)Actual problem always take priority over risk problems.
d)Nurses give the highest priority to problems that the patient thinks are most important.
✅b
A nurse is caring for an 80-year-old patient of Chinese heritage. When planning
outcomes for this patient, which actions by the nurse would meet the American Nurses
Association standards for outcomes identification? Select all that apply.
a)Developing culturally appropriate outcomes
b)Using the standardized outcomes on the clinical pathway
c)Choosing the best outcome for the patient regardless of the cost
d)Involving the patient and family in formulating the outcomes ✅a,d
A nurse is caring for an older adult client in an extended care facility. Which of the
following indicates the client has a stool impaction causing a large intestine obstruction?
a)The client reports he had a bowel movement yesterday
b)The client is having small, frequent liquid stools
c)The client is flatulent
d)The client indicates he vomited once this morning ✅b
When documenting subjective data for the cardiovascular system the nurse would
include which of the following?
a) vital signs
b) peripheral pulses
c) chest pain
d) heart sounds ✅c
When responding to questions asked during a review of systems the patient reports
having a sore throat, which "happens all the time." The nurse should ask which question
next?
a)"When did this sore throat begin?
b)"You have sore throats all of the time?"
c)"Did you also have sore throats as a child?
d)"Did you ever take antibiotics? ✅a
, During a neurological examination, the tendon reflex fails to appear. Before striking the
tendon again, you use the technique of:
a) 2 point discrimination
b) reinforcement
c) vibration
d) graphesthesia ✅b
During the assessment of the spine, the patient would be asked to:
a)Adduct and extend
b)Supinate, evert, and retract
c)Extend, adduct, invert, and rotate
d)Flex, extend, abduct, and rotate ✅d
A 70- year- old woman has come for a health examination. Which of the following is a
common age-related change in the curvature of the spinal column.
a) lordosis
b) scoliosis
c) hyphosis
d) lateral scoliosis ✅c
Examination of the shoulder includes 4 motions. These are:
a)Forward flexion, internal rotation, abduction, and external rotation.
b)Abduction, adduction, pronation, and supination.
c)Circumduction, inversion, eversion, and rotation.
d)Elevation, retraction, protraction, and circumduction. ✅a
The examiner measures a patient's legs for length discrepancy. Which is a normal
findings?
a) no difference
b) 0.5 cm difference
c) within 1 cm of each other
d) 2 cm difference ✅c
On a patient's second day in an acute care hospital, the patient complains about the
"bugs" on the bed. The bed is clean. This would be an example of altered:
a) thought process
b) orientation
c) perception
d) higher intellectual function ✅c
One way to assess cognitive function and to screen dementia with is:
a)The Proverb Interpretation Test
b)The Mini Mental Status Exam
c)The Denver Development Test
d)The Older Adult Behavior Checklist ✅b
Complete Solutions
The registered nurse (RN) is observing a nursing student auscultate the patient's breath
sounds. The RN intervenes if the nursing student performs which action?
a)Asks the patient to sit straight up
b)Instructs the patient to breathe slowly and deeply though the mouth
c)Places the stethoscope directly on the patient's skin
d)Uses the bell of the stethoscope ✅d
Which of the following would reflect an abnormality in cranial nerve III?
a)Gag reflex is absent and dysphagia is noted
b)Hearing loss is identified on the right side
c)The left pupil of the patient fails to accommodate
d)The patient is unable to chew or bite down ✅c
Which of the following is an example of an active listening behavior?
a)Taking frequent notes
b)Asking for more details
c)Leaning toward the patient
d)Sitting comfortably with legs crossed ✅c
The nurse is planning the care of a frail, immobile, elderly patient. Which of the following
is the best treatment or prevention to protect the patient's skin?
a)Administer fluid boluses as directed by the healthcare provider
b)Assisting the patient to sit in a chair three times a day
c)Offering the patient six small meals a day
d)Turning the patient at least every 2 hours ✅d
A nurse is performing an otoscopic examination of a client. Which of the following is an
unexpected finding?
a)Pearly, gray tympanic membrane (TM)
b)Malleous visible behind the TM
c)Flaky skin in the external canal near the TM
d)Black cerumen partially occluding the TM ✅d
A nurse is completing an assessment of a client who is a first generation immigrant to
the U.S. Which of the following questions should the nurse consider asking to
understand the client's culture-based nutrition habits?
a)"What type of afternoon snacks do you consume?"
b)"What type of meal do you prepare for a holiday?"
c)"What time of day do you eat breakfast?"
d)"What cooking utensils are used in food preparation?" ✅b
,A nurse is assessing a client who is in respiratory distress. The nurse should recognize
that which of the following can cause a low pulse oximetry reading? (select all that
apply)
a) nail polish
b) inadequate peripheral circualtion
c) hyperthermia
d) increased hgb level
e)edema ✅a,b,e
Which statement related to prioritizing patient problems is most accurate?
a)Nurses must resolve one problem before addressing another problem.
b)Nurses prioritize problems in order of urgency.
c)Actual problem always take priority over risk problems.
d)Nurses give the highest priority to problems that the patient thinks are most important.
✅b
A nurse is caring for an 80-year-old patient of Chinese heritage. When planning
outcomes for this patient, which actions by the nurse would meet the American Nurses
Association standards for outcomes identification? Select all that apply.
a)Developing culturally appropriate outcomes
b)Using the standardized outcomes on the clinical pathway
c)Choosing the best outcome for the patient regardless of the cost
d)Involving the patient and family in formulating the outcomes ✅a,d
A nurse is caring for an older adult client in an extended care facility. Which of the
following indicates the client has a stool impaction causing a large intestine obstruction?
a)The client reports he had a bowel movement yesterday
b)The client is having small, frequent liquid stools
c)The client is flatulent
d)The client indicates he vomited once this morning ✅b
When documenting subjective data for the cardiovascular system the nurse would
include which of the following?
a) vital signs
b) peripheral pulses
c) chest pain
d) heart sounds ✅c
When responding to questions asked during a review of systems the patient reports
having a sore throat, which "happens all the time." The nurse should ask which question
next?
a)"When did this sore throat begin?
b)"You have sore throats all of the time?"
c)"Did you also have sore throats as a child?
d)"Did you ever take antibiotics? ✅a
, During a neurological examination, the tendon reflex fails to appear. Before striking the
tendon again, you use the technique of:
a) 2 point discrimination
b) reinforcement
c) vibration
d) graphesthesia ✅b
During the assessment of the spine, the patient would be asked to:
a)Adduct and extend
b)Supinate, evert, and retract
c)Extend, adduct, invert, and rotate
d)Flex, extend, abduct, and rotate ✅d
A 70- year- old woman has come for a health examination. Which of the following is a
common age-related change in the curvature of the spinal column.
a) lordosis
b) scoliosis
c) hyphosis
d) lateral scoliosis ✅c
Examination of the shoulder includes 4 motions. These are:
a)Forward flexion, internal rotation, abduction, and external rotation.
b)Abduction, adduction, pronation, and supination.
c)Circumduction, inversion, eversion, and rotation.
d)Elevation, retraction, protraction, and circumduction. ✅a
The examiner measures a patient's legs for length discrepancy. Which is a normal
findings?
a) no difference
b) 0.5 cm difference
c) within 1 cm of each other
d) 2 cm difference ✅c
On a patient's second day in an acute care hospital, the patient complains about the
"bugs" on the bed. The bed is clean. This would be an example of altered:
a) thought process
b) orientation
c) perception
d) higher intellectual function ✅c
One way to assess cognitive function and to screen dementia with is:
a)The Proverb Interpretation Test
b)The Mini Mental Status Exam
c)The Denver Development Test
d)The Older Adult Behavior Checklist ✅b
