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NSG 3100 Exam 2 TEST FINAL EXAM AND PRACTICE EXAM
20262027 BANK 2 VERSIONS QUESTIONS WITH DETAILED
VERIFIED ANSWERS EXAM QUESTIONS WILL COME
FROM HERE (100% CORRECT ANSWERS A+ GRADED
The client's temperature at 8:00 am using an oral electronic
thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood
pressure were within normal range, what would the nurse do next?
1. Wait 15 minutes and retake it.
2. Check what the client's temperature was the last time it was taken.
3. Retake it using a different thermometer.
4. Chart the temperature; it is normal - ANSWER--Answer: 2. Rationale:
Although the temperature is slightly lower than expected for the
morning, it would be best to determine the client's previous
temperature range next. This may be a normal range for this client.
Depending on that finding, the nurse might want to retake it in a few
minutes—no need to wait 15 minutes (option 3) or with another
thermometer to see if the initial thermometer was functioning
properly. Chart after determining that the temperature has been
measured properly (option 4). Cognitive Level: Applying. Client Need:
Health Maintenance and Promotion. Nursing Process: Assessment.
Learning Outcome: 29-4.
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Which client meets the criteria for selection of the apical site for
assessment of the pulse rather than a radial pulse?
1. A client who is in shock
2. A client whose pulse changes with body position changes
3. A client with an arrhythmia
4. A client who had surgery less than 24 hours ago - ANSWER--Answer:
3. Rationale: The apical rate would confirm the rate and determine the
actual cardiac rhythm for a client with an abnormal rhythm; a radial
pulse would only reveal the heart rate and suggest an arrhythmia. For
clients in shock, use the carotid or femoral pulse (option 1). The radial
pulse is adequate for determining a change in the orthostatic heart rate
(option 2). The radial pulse is appropriate for routine postoperative
vital sign checks for clients with regular pulses (option 4). Cognitive
Level: Understanding. Client Need: Health Promotion and Maintenance.
Nursing Process: Planning. Learning Outcome: 29-5
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
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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. 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?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
NSG 3100 Exam 2 TEST FINAL EXAM AND PRACTICE EXAM
20262027 BANK 2 VERSIONS QUESTIONS WITH DETAILED
VERIFIED ANSWERS EXAM QUESTIONS WILL COME
FROM HERE (100% CORRECT ANSWERS A+ GRADED
The client's temperature at 8:00 am using an oral electronic
thermometer is 36.1°C (97.2°F). If the respiration, pulse, and blood
pressure were within normal range, what would the nurse do next?
1. Wait 15 minutes and retake it.
2. Check what the client's temperature was the last time it was taken.
3. Retake it using a different thermometer.
4. Chart the temperature; it is normal - ANSWER--Answer: 2. Rationale:
Although the temperature is slightly lower than expected for the
morning, it would be best to determine the client's previous
temperature range next. This may be a normal range for this client.
Depending on that finding, the nurse might want to retake it in a few
minutes—no need to wait 15 minutes (option 3) or with another
thermometer to see if the initial thermometer was functioning
properly. Chart after determining that the temperature has been
measured properly (option 4). Cognitive Level: Applying. Client Need:
Health Maintenance and Promotion. Nursing Process: Assessment.
Learning Outcome: 29-4.
,2|Page
Which client meets the criteria for selection of the apical site for
assessment of the pulse rather than a radial pulse?
1. A client who is in shock
2. A client whose pulse changes with body position changes
3. A client with an arrhythmia
4. A client who had surgery less than 24 hours ago - ANSWER--Answer:
3. Rationale: The apical rate would confirm the rate and determine the
actual cardiac rhythm for a client with an abnormal rhythm; a radial
pulse would only reveal the heart rate and suggest an arrhythmia. For
clients in shock, use the carotid or femoral pulse (option 1). The radial
pulse is adequate for determining a change in the orthostatic heart rate
(option 2). The radial pulse is appropriate for routine postoperative
vital sign checks for clients with regular pulses (option 4). Cognitive
Level: Understanding. Client Need: Health Promotion and Maintenance.
Nursing Process: Planning. Learning Outcome: 29-5
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
,3|Page
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. 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
, 4|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?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
