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
1
, 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: 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
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
1
, 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: 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
