NSG 3100 Exam 2, || QUESTIONS WITH ACCURATE
ANSWERS || comprehensive questions and
verified answers | GET IT RIGHT |2026!
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (30)
The client's temperature at 8:00 am Answer: 2. Rationale: Although the temperature is
using an oral electronic thermometer slightly lower than expected for the morning, it
is 36.1°C (97.2°F). If the respiration, would be best to determine the client's previous
pulse, and blood pressure were temperature range next. This may be a normal range
within normal range, what would the for this client. Depending on that finding, the nurse
nurse do next? might want to retake it in a few minutes—no need to
1. Wait 15 minutes and retake it. wait 15 minutes (option 3) or with another
2. Check what the client's temperature thermometer to see if the initial thermometer was
was the last time it 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 Need:
4. Chart the temperature; it is normal Health Maintenance and Promotion. Nursing
Process: Assessment. Learning Outcome: 29-4.
, Which client meets the criteria for Answer: 3. Rationale: The apical rate would confirm
selection of the apical site for the rate and determine the actual cardiac rhythm for
assessment of the pulse rather than a a client with an abnormal rhythm; a radial pulse
radial pulse? would only reveal the heart rate and suggest an
1. A client who is in shock arrhythmia. For clients in shock, use the carotid or
2. A client whose pulse changes with femoral pulse (option 1). The radial pulse is adequate
body position changes for determining a change in the orthostatic heart
3. A client with an arrhythmia rate (option 2). The radial pulse is appropriate for
4. A client who had surgery less than routine postoperative vital sign checks for clients
24 hours ago 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 Answer: 4. Rationale: Since the client's needs are
to measure routine vital signs, the always considered first, the measurement should be
client is on the phone. What delayed unless the client is in distress or there are
technique should the nurse use to other urgent reasons. Option 1: Respirations should
determine the respiratory rate? be measured for 30 seconds to 1 minute and are
1. Count the respirations during affected by talking. Option 2: There needs to be an
conversational pauses. important reason for interrupting the
2. Ask the client to end the phone call client. Option 3: It is inappropriate to wait and listen
now and resume it at a later time. to the client's conversation. Cognitive Level:
3. Wait at the client's bedside until the Understanding. Client Need: Health Promotion and
phone call is completed and then Maintenance. Nursing Process: Planning. Learning
count respirations. Outcome: 29-3d.
4. Since there is no evidence of
distress or urgency, postpone the
measurement until later.
ANSWERS || comprehensive questions and
verified answers | GET IT RIGHT |2026!
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (30)
The client's temperature at 8:00 am Answer: 2. Rationale: Although the temperature is
using an oral electronic thermometer slightly lower than expected for the morning, it
is 36.1°C (97.2°F). If the respiration, would be best to determine the client's previous
pulse, and blood pressure were temperature range next. This may be a normal range
within normal range, what would the for this client. Depending on that finding, the nurse
nurse do next? might want to retake it in a few minutes—no need to
1. Wait 15 minutes and retake it. wait 15 minutes (option 3) or with another
2. Check what the client's temperature thermometer to see if the initial thermometer was
was the last time it 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 Need:
4. Chart the temperature; it is normal Health Maintenance and Promotion. Nursing
Process: Assessment. Learning Outcome: 29-4.
, Which client meets the criteria for Answer: 3. Rationale: The apical rate would confirm
selection of the apical site for the rate and determine the actual cardiac rhythm for
assessment of the pulse rather than a a client with an abnormal rhythm; a radial pulse
radial pulse? would only reveal the heart rate and suggest an
1. A client who is in shock arrhythmia. For clients in shock, use the carotid or
2. A client whose pulse changes with femoral pulse (option 1). The radial pulse is adequate
body position changes for determining a change in the orthostatic heart
3. A client with an arrhythmia rate (option 2). The radial pulse is appropriate for
4. A client who had surgery less than routine postoperative vital sign checks for clients
24 hours ago 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 Answer: 4. Rationale: Since the client's needs are
to measure routine vital signs, the always considered first, the measurement should be
client is on the phone. What delayed unless the client is in distress or there are
technique should the nurse use to other urgent reasons. Option 1: Respirations should
determine the respiratory rate? be measured for 30 seconds to 1 minute and are
1. Count the respirations during affected by talking. Option 2: There needs to be an
conversational pauses. important reason for interrupting the
2. Ask the client to end the phone call client. Option 3: It is inappropriate to wait and listen
now and resume it at a later time. to the client's conversation. Cognitive Level:
3. Wait at the client's bedside until the Understanding. Client Need: Health Promotion and
phone call is completed and then Maintenance. Nursing Process: Planning. Learning
count respirations. Outcome: 29-3d.
4. Since there is no evidence of
distress or urgency, postpone the
measurement until later.
