NSG 3100 Exam 2 with correct and
verified answers 2025
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
4. Tympanic
5. Temporal artery - correct answers Answer: 3, 4, and 5. Rationale: For this client, the
nurse could take an axillary, tympanic, or temporal artery temperature. Due to the
facial drooping and difficulty swallowing, the oral route is not recommended (option 1).
Although the rectal route could be used, it would require unnecessary moving and
positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-1.
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by
which one of the following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
,NSG 3100 Exam 2 with correct and
verified answers 2025
4. Absent posterior tibial and pedal pulses - correct answers Answer: 4. Rationale: The
posterior tibial and pedal pulses in the foot are considered peripheral and at least one
of them should be palpable in normal individuals. Option 1: A bounding radial pulse is
more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are
central and not peripheral. Cognitive Level: Analyzing. Client Need: Health Promotion
and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
The nurse reports that the client has dyspnea when ambulating. The nurse is most
likely to have assessed which of the following?
1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood - correct answers Answer: 3. Rationale: Dyspnea, difficult or
labored breathing, is commonly related to inadequate oxygenation. Therefore, the
client is likely to experience shortness of breath, that is, a sense that none of the
breaths provide enough oxygen and an immediate second breath is needed. Option 1:
Shallow respirations are seen in tachypnea (rapid
breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may not
occur with dyspnea. Option 4: The medical term for coughing up blood is hemoptysis
and is unrelated to dyspnea. Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Evaluation. Learning Outcome: 29-7
When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150 mmHg:
muffled sounds continuing down to 130 mmHg; soft thumping sounds continuing down
to 105 mmHg; muffled sounds continuing down to 95 mmHg; then silence.
, NSG 3100 Exam 2 with correct and
verified answers 2025
The nurse records the blood pressure as _____________. - correct answers Answer: This
blood pressure should be recorded as 180/105/95 mmHg using the systolic/1st
diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear tapping
when deflation of the cuff begins. Phase 2 has a muffled, swishing sound. In phase 3,
blood is flowing freely via an increasingly open artery; sounds are more crisp and
more intense but softer than phase 1. Phase 4 sounds become muffled and have a soft
blowing quality. In phase 5 the last sound is heard followed by silence. Cognitive Level:
Analyzing Client Need: Health Promotion and Maintenance. Nursing Process:
Assessment. Learning Outcome: 29-9.
In Figure 29-28 •, which number indicates the client's oxygen saturation as measured
by pulse oximetry? _____________ - correct answers Answer: 4. Rationale: The SpO2 in
this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option 2
the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and option
5 the diastolic blood pressure of 84 mmHg. In addition, the client's temperature is
shown. Cognitive Level: Understanding. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-3f.
The client is a chronic carrier of infection. To prevent the spread of the infection to
other clients or health care providers, the nurse emphasizes interventions that do
which of the following?
1. Eliminate the reservoir.
2. Block the portal of exit from the reservoir.
3. Block the portal of entry into the host.
verified answers 2025
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
4. Tympanic
5. Temporal artery - correct answers Answer: 3, 4, and 5. Rationale: For this client, the
nurse could take an axillary, tympanic, or temporal artery temperature. Due to the
facial drooping and difficulty swallowing, the oral route is not recommended (option 1).
Although the rectal route could be used, it would require unnecessary moving and
positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-1.
A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by
which one of the following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
,NSG 3100 Exam 2 with correct and
verified answers 2025
4. Absent posterior tibial and pedal pulses - correct answers Answer: 4. Rationale: The
posterior tibial and pedal pulses in the foot are considered peripheral and at least one
of them should be palpable in normal individuals. Option 1: A bounding radial pulse is
more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are
central and not peripheral. Cognitive Level: Analyzing. Client Need: Health Promotion
and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
The nurse reports that the client has dyspnea when ambulating. The nurse is most
likely to have assessed which of the following?
1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood - correct answers Answer: 3. Rationale: Dyspnea, difficult or
labored breathing, is commonly related to inadequate oxygenation. Therefore, the
client is likely to experience shortness of breath, that is, a sense that none of the
breaths provide enough oxygen and an immediate second breath is needed. Option 1:
Shallow respirations are seen in tachypnea (rapid
breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may not
occur with dyspnea. Option 4: The medical term for coughing up blood is hemoptysis
and is unrelated to dyspnea. Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Evaluation. Learning Outcome: 29-7
When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150 mmHg:
muffled sounds continuing down to 130 mmHg; soft thumping sounds continuing down
to 105 mmHg; muffled sounds continuing down to 95 mmHg; then silence.
, NSG 3100 Exam 2 with correct and
verified answers 2025
The nurse records the blood pressure as _____________. - correct answers Answer: This
blood pressure should be recorded as 180/105/95 mmHg using the systolic/1st
diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear tapping
when deflation of the cuff begins. Phase 2 has a muffled, swishing sound. In phase 3,
blood is flowing freely via an increasingly open artery; sounds are more crisp and
more intense but softer than phase 1. Phase 4 sounds become muffled and have a soft
blowing quality. In phase 5 the last sound is heard followed by silence. Cognitive Level:
Analyzing Client Need: Health Promotion and Maintenance. Nursing Process:
Assessment. Learning Outcome: 29-9.
In Figure 29-28 •, which number indicates the client's oxygen saturation as measured
by pulse oximetry? _____________ - correct answers Answer: 4. Rationale: The SpO2 in
this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option 2
the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and option
5 the diastolic blood pressure of 84 mmHg. In addition, the client's temperature is
shown. Cognitive Level: Understanding. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-3f.
The client is a chronic carrier of infection. To prevent the spread of the infection to
other clients or health care providers, the nurse emphasizes interventions that do
which of the following?
1. Eliminate the reservoir.
2. Block the portal of exit from the reservoir.
3. Block the portal of entry into the host.
