NSG 3100 Exam 2 | Nursing Process, Assessment & Evidence-Based Practice Review
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:
, NSG 3100 Exam 2 | Nursing Process, Assessment & Evidence-Based Practice Review
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.
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:
, NSG 3100 Exam 2 | Nursing Process, Assessment & Evidence-Based Practice Review
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.
