NSG 3100 Exam 2 Questions for Galen
College of Nursing Complete Latest
2025/2026 with 100% Correct Answers and
Rationales highly GRADED A+
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 - CORRECT ANSWERS--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. - CORRECT ANSWERS--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 - CORRECT ANSWERS--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 - CORRECT ANSWERS--
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. The nurse
determines that which sites are most appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery - CORRECT ANSWERS--Answer: 3, 4, and 5. Rationale: For this
client, the nurse could take an axillary, tympanic, or temporal artery temperature. Due to
the facial drooping and difficulty swallowing, the oral route is not recommended (option
1). Although the rectal route could be used, it would require unnecessary moving and
positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-1.
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
College of Nursing Complete Latest
2025/2026 with 100% Correct Answers and
Rationales highly GRADED A+
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 - CORRECT ANSWERS--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. - CORRECT ANSWERS--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 - CORRECT ANSWERS--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 - CORRECT ANSWERS--
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. The nurse
determines that which sites are most appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery - CORRECT ANSWERS--Answer: 3, 4, and 5. Rationale: For this
client, the nurse could take an axillary, tympanic, or temporal artery temperature. Due to
the facial drooping and difficulty swallowing, the oral route is not recommended (option
1). Although the rectal route could be used, it would require unnecessary moving and
positioning of a client who cannot assist, and it would not provide a significant
advantage over the other routes (option 2). Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome:
29-1.
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
