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NSG 3100 Exam 2 Questions and Answers Practice
Questions ||Verified Exam!!(2 Latest Versions) with
Solutions Newest Complete Questions And Correct
Detailed Answers| Already Graded A+||Newest Exam!!!
When the nurse enters a client's room to measure routine
vital signs, the client is on the phone. What technique
should the nurse use to determine the respiratory rate?
1. Count the respirations during conversational pauses.
2. Ask the client to end the phone call now and resume it
at a later time.
3. Wait at the client's bedside until the phone call is
completed and then count respirations.
4. Since there is no evidence of distress or urgency,
postpone the measurement until later. - Answer-Answer: 4.
Rationale: Since the client's needs are always considered
first, the measurement should be delayed unless the client
is in distress or there are other urgent reasons. Option 1:
Respirations should be measured for 30 seconds to 1
minute and are affected by talking. Option 2: There needs
to be an important reason for interrupting the
client. Option 3: It is inappropriate to wait and listen to the
client's conversation. Cognitive Level: Understanding.
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Client Need: Health Promotion and Maintenance. Nursing
Process: Planning. Learning Outcome: 29-3d.
For a client with a previous blood pressure of 138/74
mmHg and pulse of 64 beats/min, approximately how long
should the nurse take to release the blood pressure cuff in
order to obtain an accurate reading?
1. 10-20 seconds
2. 30-45 seconds
3. 1-1.5 minutes
4. 3-3.5 minutes - Answer-Answer: 2. Rationale: If the cuff
is inflated to about 30 mmHg over previous systolic
pressure, that would be 168. To ensure that the diastolic
has been determined, the cuff should be released slowly
until the mid60s mmHg (and then completely) for someone
with a previous reading
of 74. The cuff should be deflated at a rate of 2 to 3 mm
per second. Thus, a range of 90 mmHg will require 30 to
45 seconds. Cognitive Level: Analyzing. Client Need:
Health Promotion and Maintenance. Nursing Process:
Implementation. Learning Outcome: 29-3e
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It would be appropriate to delegate the taking of vital signs
of which client to unlicensed assistive personnel?
1. A client being prepared for elective facial surgery with a
history of stable hypertension
2. A client receiving a blood transfusion with a history of
transfusion reactions
3. A client recently started on a new antiarrhythmic agent
4. A client who is admitted frequently with asthma attacks -
Answer-Answer: 1. Rationale: Vital signs measurement
may be delegated to UAP if the client is in stable condition,
the findings are expected to be predictable, and the
technique requires no modification. Only the preoperative
client meets these requirements. In addition, UAP are not
delegated to take apical pulse measurements for the client
with an irregular pulse as would be the case with the client
newly started on antiarrhythmic medication (option 3).
Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Planning. Learning
Outcome: 29-8.
An 85-year-old client has had a stroke resulting in right-
sided facial drooping, difficulty swallowing, and the inability
to move self or maintain position unaided. The nurse
determines that which sites are most appropriate for taking
the temperature?
NSG 3100 Exam 2 Questions and Answers Practice
Questions ||Verified Exam!!(2 Latest Versions) with
Solutions Newest Complete Questions And Correct
Detailed Answers| Already Graded A+||Newest Exam!!!
When the nurse enters a client's room to measure routine
vital signs, the client is on the phone. What technique
should the nurse use to determine the respiratory rate?
1. Count the respirations during conversational pauses.
2. Ask the client to end the phone call now and resume it
at a later time.
3. Wait at the client's bedside until the phone call is
completed and then count respirations.
4. Since there is no evidence of distress or urgency,
postpone the measurement until later. - Answer-Answer: 4.
Rationale: Since the client's needs are always considered
first, the measurement should be delayed unless the client
is in distress or there are other urgent reasons. Option 1:
Respirations should be measured for 30 seconds to 1
minute and are affected by talking. Option 2: There needs
to be an important reason for interrupting the
client. Option 3: It is inappropriate to wait and listen to the
client's conversation. Cognitive Level: Understanding.
,2|Page
Client Need: Health Promotion and Maintenance. Nursing
Process: Planning. Learning Outcome: 29-3d.
For a client with a previous blood pressure of 138/74
mmHg and pulse of 64 beats/min, approximately how long
should the nurse take to release the blood pressure cuff in
order to obtain an accurate reading?
1. 10-20 seconds
2. 30-45 seconds
3. 1-1.5 minutes
4. 3-3.5 minutes - Answer-Answer: 2. Rationale: If the cuff
is inflated to about 30 mmHg over previous systolic
pressure, that would be 168. To ensure that the diastolic
has been determined, the cuff should be released slowly
until the mid60s mmHg (and then completely) for someone
with a previous reading
of 74. The cuff should be deflated at a rate of 2 to 3 mm
per second. Thus, a range of 90 mmHg will require 30 to
45 seconds. Cognitive Level: Analyzing. Client Need:
Health Promotion and Maintenance. Nursing Process:
Implementation. Learning Outcome: 29-3e
, 3|Page
It would be appropriate to delegate the taking of vital signs
of which client to unlicensed assistive personnel?
1. A client being prepared for elective facial surgery with a
history of stable hypertension
2. A client receiving a blood transfusion with a history of
transfusion reactions
3. A client recently started on a new antiarrhythmic agent
4. A client who is admitted frequently with asthma attacks -
Answer-Answer: 1. Rationale: Vital signs measurement
may be delegated to UAP if the client is in stable condition,
the findings are expected to be predictable, and the
technique requires no modification. Only the preoperative
client meets these requirements. In addition, UAP are not
delegated to take apical pulse measurements for the client
with an irregular pulse as would be the case with the client
newly started on antiarrhythmic medication (option 3).
Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Planning. Learning
Outcome: 29-8.
An 85-year-old client has had a stroke resulting in right-
sided facial drooping, difficulty swallowing, and the inability
to move self or maintain position unaided. The nurse
determines that which sites are most appropriate for taking
the temperature?
