NSG 3100 Exam 2 | Newest Questions
and Answers | 2026 Update | Expert
Verified
• 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.
• 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
• 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: 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: 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: 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.
and Answers | 2026 Update | Expert
Verified
• 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.
• 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
• 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: 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: 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: 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.
