NR 304 FINAL EXAM
NR 304 Final Exam Questions with
Verified Answers 2025
What happens during the evaluation step of the nursing process? - Correct Ans-Progress
towards outcomes, use ongoing assessment to revise diagnoses/outcomes/plans,
disseminate results to patient and family
What happens during the diagnosis stage of the nursing process? - Correct Ans-Compare
clinical findings with normal and abnormal variation and developmental events,
interpret data, validate and document diagnoses.
What is a problem center database? Give an example. - Correct Ans-For limited or short
term problems. Collect mini/targeted databases. Focuses on only one problem or body
system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough and fatigue;
focus on respiratory and cardiovascular systems
What are the components of a general survey? - Correct Ans-Begins during first patient
encounter.. Includes their physical appearance, body structure, mobility, behavior, body
measurements
What is the grading of pulse force? - Correct Ans-3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent
What are causes of hypotension? - Correct Ans-Acute myocardial infarction, shock,
hemorrhage, vasodilation, Addison's disease
1|Page
,NR 304 FINAL EXAM
What is the blood pressure measurement for hypotension? - Correct Ans-Less than
95/60 mmHg
Acute myocardial infarction and shark causes a _____ cardiac output which leads to
hypertension? - Correct Ans-Decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension - Correct Ans-
decreased
Vasodilation causes a ____peripheral vascular resistance that leads to hypotension -
Correct Ans-decreased
Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating
aldosterone which causes hypotension - Correct Ans-decreased
How do you count respirations? - Correct Ans-Count while assessing radial pulse to make
patient unaware that you were counting respirations. Count for 30 seconds of normal or
1 minute if abnormal
What are the effects of smoking on blood pressure? - Correct Ans-Vasoconstriction of
the arteries which makes your blood pressure increase. Long-term cause of hypertension
What is the ABCDEF skin lesions mean? - Correct Ans-Asymmetry, border irregularity,
color variation, diameter greater than 6mm, elevation/evolution, funny looking
What are the physiological changes associated with acute pain responses? - Correct Ans-
Tachycardia, elevated blood pressure, increased cardiac output, hypoxia,
hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria, urinary
2|Page
,NR 304 FINAL EXAM
retention, spasm, joint stiffness, increased adrenergic activity, fear, anxiety, fatigue,
impaired immunity, wound healing
How do you assess for clubbing? - Correct Ans-Put nail beds back to back and view
profile sign index. Normal is 160°. Early clubbing is 180° and lake clubbing is anything
less than 160°
What patients does clubbing occur? - Correct Ans-Smoking, lung cancer, pulmonary
disease, congenital cyanotic heart disease
How do you detect pallor in a light skinned patient? - Correct Ans-Generalized pallor
How do you detect pallor in a dark skinned patient? - Correct Ans-Ashen gray, dull, loss
of glow, cool to palpation
How do you detect jaundice in a light-skinned patient? - Correct Ans-Yellow sclera, hard
palate, skin, mucous membranes
How do you observe jaundice in a dark skinned patient? - Correct Ans-Observe the
palms, hard and soft palates
How do you observe cyanosis in a light skinned patient? - Correct Ans-Dusky blue
appearance
How do you observe cyanosis in a dark skinned patient? - Correct Ans-Dullness, check
conjunctiva, oral cavity, nails
How do you observe erythema in a light skin patient? - Correct Ans-Red or bright pink
color
3|Page
, NR 304 FINAL EXAM
How do you observe erythema in a dark skinned patient? - Correct Ans-Purpleish tinge,
difficult to observe, palpate for warmth
What is the name and characteristics of a stage one pressure injury? - Correct Ans-Stage
1 non-blanchable erythema
Intact skin with a localized area of non-blanchable erythema
What is the name and characteristics of a stage 2 pressure injury? - Correct Ans-Stage 2
partial thickness skin loss
Partial skin loss with an exposed dermis. Pink/red and moist visible wound base. Looks
like a ruptured blister. Usually associated with moisture. Slough and eschar not noted.
What is the name and characteristics of a stage 3 pressure injury? - Correct Ans-Stage 3:
Full-Thickness Skin Loss
For thickness loss of skin. Adipose is visible in ulcer and granulation tissue with epibole.
Slough and eschar may be noted. Tunneling and undermining may occur.
What's the name and characteristic of a stage 4 pressure injury? - Correct Ans-Stage 4:
Full thickness skin/tissue loss
Full thickness skin and tissue loss with muscle/bone/tendon/ligament exposed. Slough,
Eschar, epibole, undermining, tunneling may be present.
How do you assess the range of motion of the neck? - Correct Ans-Touch chin to chest,
turn head right and left, touch ear with shoulder without elevating the shoulders, extend
head backwards
4|Page
NR 304 Final Exam Questions with
Verified Answers 2025
What happens during the evaluation step of the nursing process? - Correct Ans-Progress
towards outcomes, use ongoing assessment to revise diagnoses/outcomes/plans,
disseminate results to patient and family
What happens during the diagnosis stage of the nursing process? - Correct Ans-Compare
clinical findings with normal and abnormal variation and developmental events,
interpret data, validate and document diagnoses.
What is a problem center database? Give an example. - Correct Ans-For limited or short
term problems. Collect mini/targeted databases. Focuses on only one problem or body
system and is used in all clinical settings.
Ex: two days post-op patient suddenly becomes SOB with congestive cough and fatigue;
focus on respiratory and cardiovascular systems
What are the components of a general survey? - Correct Ans-Begins during first patient
encounter.. Includes their physical appearance, body structure, mobility, behavior, body
measurements
What is the grading of pulse force? - Correct Ans-3+ Full, bounding
2+ Normal
1+ Weak, thready
0 Absent
What are causes of hypotension? - Correct Ans-Acute myocardial infarction, shock,
hemorrhage, vasodilation, Addison's disease
1|Page
,NR 304 FINAL EXAM
What is the blood pressure measurement for hypotension? - Correct Ans-Less than
95/60 mmHg
Acute myocardial infarction and shark causes a _____ cardiac output which leads to
hypertension? - Correct Ans-Decreased
Hemorrhage causes a _____ total blood volume that leads to hypotension - Correct Ans-
decreased
Vasodilation causes a ____peripheral vascular resistance that leads to hypotension -
Correct Ans-decreased
Addison's disease (hypofunction of adrenal gland) is caused by a ___ circulating
aldosterone which causes hypotension - Correct Ans-decreased
How do you count respirations? - Correct Ans-Count while assessing radial pulse to make
patient unaware that you were counting respirations. Count for 30 seconds of normal or
1 minute if abnormal
What are the effects of smoking on blood pressure? - Correct Ans-Vasoconstriction of
the arteries which makes your blood pressure increase. Long-term cause of hypertension
What is the ABCDEF skin lesions mean? - Correct Ans-Asymmetry, border irregularity,
color variation, diameter greater than 6mm, elevation/evolution, funny looking
What are the physiological changes associated with acute pain responses? - Correct Ans-
Tachycardia, elevated blood pressure, increased cardiac output, hypoxia,
hypoventilation, atelectasis, decreased cough, nausea, vomiting, ileus, oliguria, urinary
2|Page
,NR 304 FINAL EXAM
retention, spasm, joint stiffness, increased adrenergic activity, fear, anxiety, fatigue,
impaired immunity, wound healing
How do you assess for clubbing? - Correct Ans-Put nail beds back to back and view
profile sign index. Normal is 160°. Early clubbing is 180° and lake clubbing is anything
less than 160°
What patients does clubbing occur? - Correct Ans-Smoking, lung cancer, pulmonary
disease, congenital cyanotic heart disease
How do you detect pallor in a light skinned patient? - Correct Ans-Generalized pallor
How do you detect pallor in a dark skinned patient? - Correct Ans-Ashen gray, dull, loss
of glow, cool to palpation
How do you detect jaundice in a light-skinned patient? - Correct Ans-Yellow sclera, hard
palate, skin, mucous membranes
How do you observe jaundice in a dark skinned patient? - Correct Ans-Observe the
palms, hard and soft palates
How do you observe cyanosis in a light skinned patient? - Correct Ans-Dusky blue
appearance
How do you observe cyanosis in a dark skinned patient? - Correct Ans-Dullness, check
conjunctiva, oral cavity, nails
How do you observe erythema in a light skin patient? - Correct Ans-Red or bright pink
color
3|Page
, NR 304 FINAL EXAM
How do you observe erythema in a dark skinned patient? - Correct Ans-Purpleish tinge,
difficult to observe, palpate for warmth
What is the name and characteristics of a stage one pressure injury? - Correct Ans-Stage
1 non-blanchable erythema
Intact skin with a localized area of non-blanchable erythema
What is the name and characteristics of a stage 2 pressure injury? - Correct Ans-Stage 2
partial thickness skin loss
Partial skin loss with an exposed dermis. Pink/red and moist visible wound base. Looks
like a ruptured blister. Usually associated with moisture. Slough and eschar not noted.
What is the name and characteristics of a stage 3 pressure injury? - Correct Ans-Stage 3:
Full-Thickness Skin Loss
For thickness loss of skin. Adipose is visible in ulcer and granulation tissue with epibole.
Slough and eschar may be noted. Tunneling and undermining may occur.
What's the name and characteristic of a stage 4 pressure injury? - Correct Ans-Stage 4:
Full thickness skin/tissue loss
Full thickness skin and tissue loss with muscle/bone/tendon/ligament exposed. Slough,
Eschar, epibole, undermining, tunneling may be present.
How do you assess the range of motion of the neck? - Correct Ans-Touch chin to chest,
turn head right and left, touch ear with shoulder without elevating the shoulders, extend
head backwards
4|Page
