NSG 3100 Exam 2 Questions with Verified Solutions (Fully Solved)

NSG 3100 Exam 2 Questions with Verified Solutions (Fully Solved) 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 - Answers 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 - 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. - 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 - 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 - 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 - 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 4. Absent posterior tibial and pedal pulses - Answers Answer: 4. Rationale: The posterior tibial and pedal pulses in the foot are considered peripheral and at least one of them should be palpable in normal individuals. Option 1: A bounding radial pulse is more indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are central and not peripheral. Cognitive Level: Analyzing. Client Need: Health Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9. The nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following? 1. Shallow respirations 2. Wheezing