NSG 3100: Exam 2 | 100% Correct
Questions & Detailed Rationales
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.
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
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
Questions & Detailed Rationales
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.
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
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
