NSG 3100 Exam 2 Questions and Answers with
Complete Solutions | 2026 Newly Updated |
Galen College of Nursing
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Terms in this set (30)
The client's temperature at 8:00 am Answer: 2. Rationale: Although the temperature is
using an oral electronic slightly lower than expected for the morning, it
thermometer is 36.1°C (97.2°F). If the would be best to determine the client's previous
respiration, pulse, and blood temperature range next. This may be a normal
pressure were within normal range, range for this client. Depending on that finding,
what would the nurse do next? the nurse might want to retake it in a few minutes
1. Wait 15 minutes and retake it. —no need to wait 15 minutes (option 3) or with
2. Check what the client's another
temperature was the last time it was thermometer to see if the initial thermometer was
taken. functioning properly. Chart after determining that
3. Retake it using a different the temperature has been measured properly
thermometer. (option 4). Cognitive Level: Applying. Client
4. Chart the temperature; it is Need: Health Maintenance and Promotion.
normal Nursing Process: Assessment. Learning Outcome:
29-4.
,Which client meets the criteria for Answer: 3. Rationale: The apical rate would
selection of the apical site for confirm the rate and determine the actual cardiac
assessment of the pulse rather than rhythm for a client with an abnormal rhythm; a
a radial pulse? radial pulse would only reveal the heart rate and
1. A client who is in shock suggest an arrhythmia. For clients in shock, use
2. A client whose pulse changes the carotid or femoral pulse (option 1). The radial
with body position changes pulse is adequate for determining a change in the
3. A client with an arrhythmia orthostatic heart rate (option 2). The radial pulse
4. A client who had surgery less is appropriate for routine postoperative vital sign
than 24 hours ago 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 Answer: 4. Rationale: Since the client's needs are
room to measure routine vital signs, always considered first, the measurement should
the client is on the phone. What be delayed unless the client is in distress or there
technique should the nurse use to are other urgent reasons. Option 1: Respirations
determine the respiratory rate? should be measured for 30 seconds to 1 minute
1. Count the respirations during and are affected by talking. Option 2: There
conversational pauses. needs to be an important reason for interrupting
2. Ask the client to end the phone the
call now and resume it at a later client. Option 3: It is inappropriate to wait and
time. listen to the client's conversation. Cognitive Level:
3. Wait at the client's bedside until Understanding. Client Need: Health Promotion
the phone call is completed and and Maintenance. Nursing Process: Planning.
then count respirations. Learning Outcome: 29-3d.
4. Since there is no evidence of
distress or urgency, postpone the
measurement until later.
, For a client with a previous blood Answer: 2. Rationale: If the cuff is inflated to
pressure of 138/74 mmHg and pulse about 30 mmHg over previous systolic pressure,
of 64 beats/min, approximately how that would be 168. To ensure that the diastolic
long should the nurse take to has been determined, the cuff should be
release the blood pressure cuff in released slowly until the mid60s mmHg (and then
order to obtain an accurate completely) for someone with a previous reading
reading? of 74. The cuff should be deflated at a rate of 2 to
1. 10-20 seconds 3 mm per second. Thus, a range of 90 mmHg will
2. 30-45 seconds require 30 to 45 seconds. Cognitive Level:
3. 1-1.5 minutes Analyzing. Client Need: Health Promotion and
4. 3-3.5 minutes Maintenance. Nursing Process: Implementation.
Learning Outcome: 29-3e
It would be appropriate to Answer: 1. Rationale: Vital signs measurement may
delegate the taking of vital signs of be delegated to UAP if the client is in stable
which client to unlicensed assistive condition, the findings are expected to be
personnel? predictable, and the technique requires no
1. A client being prepared for modification. Only the preoperative client meets
elective facial surgery with a history these requirements. In addition, UAP are not
of stable hypertension delegated to take apical pulse measurements for
2. A client receiving a blood the client with an irregular pulse as would be the
transfusion with a history of case with the client newly started on
transfusion reactions antiarrhythmic medication (option 3). Cognitive
3. A client recently started on a new Level: Applying. Client Need: Health Promotion
antiarrhythmic agent and Maintenance. Nursing Process: Planning.
4. A client who is admitted Learning Outcome: 29-8.
frequently with asthma attacks
Complete Solutions | 2026 Newly Updated |
Galen College of Nursing
Save
Terms in this set (30)
The client's temperature at 8:00 am Answer: 2. Rationale: Although the temperature is
using an oral electronic slightly lower than expected for the morning, it
thermometer is 36.1°C (97.2°F). If the would be best to determine the client's previous
respiration, pulse, and blood temperature range next. This may be a normal
pressure were within normal range, range for this client. Depending on that finding,
what would the nurse do next? the nurse might want to retake it in a few minutes
1. Wait 15 minutes and retake it. —no need to wait 15 minutes (option 3) or with
2. Check what the client's another
temperature was the last time it was thermometer to see if the initial thermometer was
taken. functioning properly. Chart after determining that
3. Retake it using a different the temperature has been measured properly
thermometer. (option 4). Cognitive Level: Applying. Client
4. Chart the temperature; it is Need: Health Maintenance and Promotion.
normal Nursing Process: Assessment. Learning Outcome:
29-4.
,Which client meets the criteria for Answer: 3. Rationale: The apical rate would
selection of the apical site for confirm the rate and determine the actual cardiac
assessment of the pulse rather than rhythm for a client with an abnormal rhythm; a
a radial pulse? radial pulse would only reveal the heart rate and
1. A client who is in shock suggest an arrhythmia. For clients in shock, use
2. A client whose pulse changes the carotid or femoral pulse (option 1). The radial
with body position changes pulse is adequate for determining a change in the
3. A client with an arrhythmia orthostatic heart rate (option 2). The radial pulse
4. A client who had surgery less is appropriate for routine postoperative vital sign
than 24 hours ago 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 Answer: 4. Rationale: Since the client's needs are
room to measure routine vital signs, always considered first, the measurement should
the client is on the phone. What be delayed unless the client is in distress or there
technique should the nurse use to are other urgent reasons. Option 1: Respirations
determine the respiratory rate? should be measured for 30 seconds to 1 minute
1. Count the respirations during and are affected by talking. Option 2: There
conversational pauses. needs to be an important reason for interrupting
2. Ask the client to end the phone the
call now and resume it at a later client. Option 3: It is inappropriate to wait and
time. listen to the client's conversation. Cognitive Level:
3. Wait at the client's bedside until Understanding. Client Need: Health Promotion
the phone call is completed and and Maintenance. Nursing Process: Planning.
then count respirations. Learning Outcome: 29-3d.
4. Since there is no evidence of
distress or urgency, postpone the
measurement until later.
, For a client with a previous blood Answer: 2. Rationale: If the cuff is inflated to
pressure of 138/74 mmHg and pulse about 30 mmHg over previous systolic pressure,
of 64 beats/min, approximately how that would be 168. To ensure that the diastolic
long should the nurse take to has been determined, the cuff should be
release the blood pressure cuff in released slowly until the mid60s mmHg (and then
order to obtain an accurate completely) for someone with a previous reading
reading? of 74. The cuff should be deflated at a rate of 2 to
1. 10-20 seconds 3 mm per second. Thus, a range of 90 mmHg will
2. 30-45 seconds require 30 to 45 seconds. Cognitive Level:
3. 1-1.5 minutes Analyzing. Client Need: Health Promotion and
4. 3-3.5 minutes Maintenance. Nursing Process: Implementation.
Learning Outcome: 29-3e
It would be appropriate to Answer: 1. Rationale: Vital signs measurement may
delegate the taking of vital signs of be delegated to UAP if the client is in stable
which client to unlicensed assistive condition, the findings are expected to be
personnel? predictable, and the technique requires no
1. A client being prepared for modification. Only the preoperative client meets
elective facial surgery with a history these requirements. In addition, UAP are not
of stable hypertension delegated to take apical pulse measurements for
2. A client receiving a blood the client with an irregular pulse as would be the
transfusion with a history of case with the client newly started on
transfusion reactions antiarrhythmic medication (option 3). Cognitive
3. A client recently started on a new Level: Applying. Client Need: Health Promotion
antiarrhythmic agent and Maintenance. Nursing Process: Planning.
4. A client who is admitted Learning Outcome: 29-8.
frequently with asthma attacks
