NUR 3100 EXAM 2 QUESTIONS & ANSWERS
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
4. A client who is admitted frequently with asthma attacks - 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.
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
4. Absent posterior tibial and pedal pulses - Answer -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 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
4. A client who is admitted frequently with asthma attacks - 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.
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
4. Absent posterior tibial and pedal pulses - Answer -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.
