NSG 3100 Exam 2 Questions with 100% Correct Answers | Latest Version 2024 | 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 an