NSG 3100 Exam 2: Fundamental Concepts &
Skills for Nursing Practice With Practice
Questions And Verified Answers Plus
Rationales
## SECTION 1: VITAL SIGNS & THERMOREGULATION
---
**1. 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?**
- A. Wait 15 minutes and retake it.
- B. Check what the client's temperature was the last time it was taken.
- C. Retake it using a different thermometer.
- D. Chart the temperature; it is normal.
**Answer: B. Check what the client's temperature was the last time it was taken.**
**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 or use a different
thermometer to see if the initial thermometer was functioning properly. Chart after
determining that the temperature has been measured properly.
---
,**2. Which client meets the criteria for selection of the apical site for assessment of
the pulse rather than a radial pulse?**
- A. A client who is in shock
- B. A client whose pulse changes with body position changes
- C. A client with an arrhythmia
- D. A client who had surgery less than 24 hours ago
**Answer: C. A client with an arrhythmia**
**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.
The radial pulse is adequate for determining a change in the orthostatic heart rate and
is appropriate for routine postoperative vital sign checks for clients with regular
pulses.
---
**3. 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?**
- A. Count the respirations during conversational pauses.
- B. Ask the client to end the phone call now and resume it at a later time.
- C. Wait at the client's bedside until the phone call is completed and then count
respirations.
- D. Since there is no evidence of distress or urgency, postpone the measurement until
later.
,**Answer: D. Since there is no evidence of distress or urgency, postpone the
measurement until later.**
**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.
Respirations should be measured for 30 seconds to 1 minute and are affected by
talking. It is inappropriate to wait and listen to the client's phone conversation.
---
**4. What is the "Guiding Principle" a nurse should follow when assessing vital
signs?**
- A. Always trust the machine over the patient
- B. Don't treat the number, treat the patient
- C. Only record values that fall within the normal range
- D. Re-check every abnormal value four times
**Answer: B. Don't treat the number, treat the patient**
**Rationale:** The guiding principle in vital signs assessment is to treat the patient, not
just the number. Vital signs must be interpreted in the context of the patient's overall
clinical presentation, baseline values, and condition.
---
**5. Which physiological response occurs when the body becomes too cold
(hypothermia)?**
- A. Vasodilation and sweating
, - B. Decreased metabolic rate
- C. Vasoconstriction and shivering
- D. Increased skin temperature
**Answer: C. Vasoconstriction and shivering**
**Rationale:** When the body becomes too cold, it responds with vasoconstriction to
reduce heat loss and shivering to generate heat through muscle activity. Vasodilation
and sweating are responses to hyperthermia.
---
**6. Which of the following factors affects blood pressure?**
- A. Age, gender, race, and diurnal rhythm
- B. Weight, exercise, emotions, and stress
- C. Both A and B
- D. None of the above
**Answer: C. Both A and B**
**Rationale:** Blood pressure is affected by multiple factors including age, gender,
race, diurnal rhythm, weight, exercise, emotions, and stress. All of these can influence
both systolic and diastolic readings.
---
**7. Which of the following factors affects pulse rate?**
Skills for Nursing Practice With Practice
Questions And Verified Answers Plus
Rationales
## SECTION 1: VITAL SIGNS & THERMOREGULATION
---
**1. 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?**
- A. Wait 15 minutes and retake it.
- B. Check what the client's temperature was the last time it was taken.
- C. Retake it using a different thermometer.
- D. Chart the temperature; it is normal.
**Answer: B. Check what the client's temperature was the last time it was taken.**
**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 or use a different
thermometer to see if the initial thermometer was functioning properly. Chart after
determining that the temperature has been measured properly.
---
,**2. Which client meets the criteria for selection of the apical site for assessment of
the pulse rather than a radial pulse?**
- A. A client who is in shock
- B. A client whose pulse changes with body position changes
- C. A client with an arrhythmia
- D. A client who had surgery less than 24 hours ago
**Answer: C. A client with an arrhythmia**
**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.
The radial pulse is adequate for determining a change in the orthostatic heart rate and
is appropriate for routine postoperative vital sign checks for clients with regular
pulses.
---
**3. 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?**
- A. Count the respirations during conversational pauses.
- B. Ask the client to end the phone call now and resume it at a later time.
- C. Wait at the client's bedside until the phone call is completed and then count
respirations.
- D. Since there is no evidence of distress or urgency, postpone the measurement until
later.
,**Answer: D. Since there is no evidence of distress or urgency, postpone the
measurement until later.**
**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.
Respirations should be measured for 30 seconds to 1 minute and are affected by
talking. It is inappropriate to wait and listen to the client's phone conversation.
---
**4. What is the "Guiding Principle" a nurse should follow when assessing vital
signs?**
- A. Always trust the machine over the patient
- B. Don't treat the number, treat the patient
- C. Only record values that fall within the normal range
- D. Re-check every abnormal value four times
**Answer: B. Don't treat the number, treat the patient**
**Rationale:** The guiding principle in vital signs assessment is to treat the patient, not
just the number. Vital signs must be interpreted in the context of the patient's overall
clinical presentation, baseline values, and condition.
---
**5. Which physiological response occurs when the body becomes too cold
(hypothermia)?**
- A. Vasodilation and sweating
, - B. Decreased metabolic rate
- C. Vasoconstriction and shivering
- D. Increased skin temperature
**Answer: C. Vasoconstriction and shivering**
**Rationale:** When the body becomes too cold, it responds with vasoconstriction to
reduce heat loss and shivering to generate heat through muscle activity. Vasodilation
and sweating are responses to hyperthermia.
---
**6. Which of the following factors affects blood pressure?**
- A. Age, gender, race, and diurnal rhythm
- B. Weight, exercise, emotions, and stress
- C. Both A and B
- D. None of the above
**Answer: C. Both A and B**
**Rationale:** Blood pressure is affected by multiple factors including age, gender,
race, diurnal rhythm, weight, exercise, emotions, and stress. All of these can influence
both systolic and diastolic readings.
---
**7. Which of the following factors affects pulse rate?**
