NSG 3100 Exam 2 Comprehensive
Questions (Frequently Tested) with
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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.
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
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.
Questions (Frequently Tested) with
Verified Answers Graded A+
Professional Academic Assistance Services
Services Offered
• Proctored Exam Assistance
• Online Class Management (Full Course Support)
• Exam Preparation & Study Materials
• Assignments and Coursework Support
• Essay and Research Paper Writing
• Discussion Posts & Responses
• Editing and Proofreading
• Confidential Academic Consultation
Helping Students Achieve Academic Excellence
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.
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
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.
