,NSG 3100 Exam 2 – Fundamental Concepts & Skills
I – Actual Q&A (GCN) (Updated PDF)
1. The nurse enters a client’s room to measure routine vital signs and finds the
client talking on the phone. The client appears comfortable. What should the
nurse do?
A) Count the respirations during conversational pauses.
B) Ask the client to end the call immediately.
C) Wait at the bedside until the call ends.
D) Postpone the measurement until the call is completed.
Correct Answer: D) Postpone the measurement until the call is completed.
Rationale: Talking alters respirations, heart rate, and blood pressure. Since the
client is stable, the nurse should respect the client’s privacy and wait. Forcing
interruption or counting during speech yields inaccurate data and disregards
client-centered care.
2. The nurse is preparing to assess an older adult’s oral temperature. Which
factor has the greatest potential to alter the accuracy of this reading?
A) Drinking cold liquids 30 minutes ago
B) Ambulating in the hallway 20 minutes ago
C) Wearing a hearing aid
D) Using an alcohol-based mouthwash
Correct Answer: A) Drinking cold liquids 30 minutes ago
,Rationale: Ingesting hot or cold liquids can transiently alter oral temperature for
up to 15–30 minutes. The nurse should wait at least 15–30 minutes after
ingestion. Mouthwash may have minimal effect. Ambulation might slightly raise
temperature but not as directly.
3. A 72-year-old patient is found to have an oral temperature of 36.1°C (97.2°F)
at 8:00 a.m. All other vital signs are within normal limits. What should the nurse
do first?
A) Retake the temperature using a tympanic thermometer.
B) Review the patient’s previous temperature readings.
C) Notify the healthcare provider immediately.
D) Document the temperature as a normal finding.
Correct Answer: B) Review the patient’s previous temperature readings.
Rationale: While slightly lower than the average morning temperature, this may
be normal for the older adult. Checking the trend before acting is appropriate.
Retaking or notifying the provider is premature. Documentation occurs after
verification.
4. The unlicensed assistive personnel (UAP) reports a patient’s tympanic
temperature as 38.8°C (101.8°F). Which action should the nurse take first?
A) Instruct the UAP to retake the temperature.
B) Document the finding in the electronic health record.
C) Assess the patient for other signs of infection.
D) Administer acetaminophen as prescribed.
, Correct Answer: C) Assess the patient for other signs of infection.
Rationale: The nurse must first perform a focused assessment to determine the
significance of the elevated temperature. Retaking may be done, but
assessment precedes intervention. Administering medication requires a
comprehensive evaluation.
5. The nurse is obtaining a blood pressure on a patient with a known
arteriovenous fistula in the left arm. Which action is most appropriate?
A) Apply the cuff to the left arm just below the fistula.
B) Use the left arm, inflating the cuff slowly.
C) Obtain the blood pressure on the right arm.
D) Place the cuff on the forearm of the left arm.
Correct Answer: C) Obtain the blood pressure on the right arm.
Rationale: A limb with an arteriovenous fistula or shunt should never be used
for blood pressure measurement; compression could damage the fistula. The
opposite arm must be used.
6. The nurse is assessing a patient for orthostatic hypotension. After obtaining a
supine blood pressure of 128/76 mmHg, the nurse assists the patient to stand.
After 2 minutes, the blood pressure is 106/62 mmHg and the patient reports
dizziness. What is the best interpretation?
A) The response is normal.
B) The patient is experiencing a hypertensive episode.
C) The findings indicate orthostatic hypotension.
I – Actual Q&A (GCN) (Updated PDF)
1. The nurse enters a client’s room to measure routine vital signs and finds the
client talking on the phone. The client appears comfortable. What should the
nurse do?
A) Count the respirations during conversational pauses.
B) Ask the client to end the call immediately.
C) Wait at the bedside until the call ends.
D) Postpone the measurement until the call is completed.
Correct Answer: D) Postpone the measurement until the call is completed.
Rationale: Talking alters respirations, heart rate, and blood pressure. Since the
client is stable, the nurse should respect the client’s privacy and wait. Forcing
interruption or counting during speech yields inaccurate data and disregards
client-centered care.
2. The nurse is preparing to assess an older adult’s oral temperature. Which
factor has the greatest potential to alter the accuracy of this reading?
A) Drinking cold liquids 30 minutes ago
B) Ambulating in the hallway 20 minutes ago
C) Wearing a hearing aid
D) Using an alcohol-based mouthwash
Correct Answer: A) Drinking cold liquids 30 minutes ago
,Rationale: Ingesting hot or cold liquids can transiently alter oral temperature for
up to 15–30 minutes. The nurse should wait at least 15–30 minutes after
ingestion. Mouthwash may have minimal effect. Ambulation might slightly raise
temperature but not as directly.
3. A 72-year-old patient is found to have an oral temperature of 36.1°C (97.2°F)
at 8:00 a.m. All other vital signs are within normal limits. What should the nurse
do first?
A) Retake the temperature using a tympanic thermometer.
B) Review the patient’s previous temperature readings.
C) Notify the healthcare provider immediately.
D) Document the temperature as a normal finding.
Correct Answer: B) Review the patient’s previous temperature readings.
Rationale: While slightly lower than the average morning temperature, this may
be normal for the older adult. Checking the trend before acting is appropriate.
Retaking or notifying the provider is premature. Documentation occurs after
verification.
4. The unlicensed assistive personnel (UAP) reports a patient’s tympanic
temperature as 38.8°C (101.8°F). Which action should the nurse take first?
A) Instruct the UAP to retake the temperature.
B) Document the finding in the electronic health record.
C) Assess the patient for other signs of infection.
D) Administer acetaminophen as prescribed.
, Correct Answer: C) Assess the patient for other signs of infection.
Rationale: The nurse must first perform a focused assessment to determine the
significance of the elevated temperature. Retaking may be done, but
assessment precedes intervention. Administering medication requires a
comprehensive evaluation.
5. The nurse is obtaining a blood pressure on a patient with a known
arteriovenous fistula in the left arm. Which action is most appropriate?
A) Apply the cuff to the left arm just below the fistula.
B) Use the left arm, inflating the cuff slowly.
C) Obtain the blood pressure on the right arm.
D) Place the cuff on the forearm of the left arm.
Correct Answer: C) Obtain the blood pressure on the right arm.
Rationale: A limb with an arteriovenous fistula or shunt should never be used
for blood pressure measurement; compression could damage the fistula. The
opposite arm must be used.
6. The nurse is assessing a patient for orthostatic hypotension. After obtaining a
supine blood pressure of 128/76 mmHg, the nurse assists the patient to stand.
After 2 minutes, the blood pressure is 106/62 mmHg and the patient reports
dizziness. What is the best interpretation?
A) The response is normal.
B) The patient is experiencing a hypertensive episode.
C) The findings indicate orthostatic hypotension.
