NSG 3100 EXAM 2 2025 | ALL QUESTIONS AND CORRECT ANSWERS |
VERIFIED ANSWERS | LATEST EXAM | ALREADY GRADED A+
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 -
5. 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 -
5. 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. -
5. 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.
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 -
5. 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
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 -
5. 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
4. Tympanic
5. Temporal artery -
6. Answer-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).
VERIFIED ANSWERS | LATEST EXAM | ALREADY GRADED A+
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 -
5. 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 -
5. 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. -
5. 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.
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 -
5. 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
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 -
5. 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
4. Tympanic
5. Temporal artery -
6. Answer-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).
