NSG 3100 Exam 2
1. 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: 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. 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: 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
3. 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.
, NSG 3100 Exam 2
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: 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.
4. 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: 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
5. 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: 1.
Rationale: Vital signs measurement may be delegated to UAP if the client is in
1. 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: 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. 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: 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
3. 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.
, NSG 3100 Exam 2
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: 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.
4. 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: 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
5. 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: 1.
Rationale: Vital signs measurement may be delegated to UAP if the client is in
