NSG 3100 EXAM 2 | QUESTIONS AND ANSWERS | 2026
UPDATE | CORRECT ANSWERS | WITH DETAILED
SOLUTIONS
• 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: 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. -✓✓ 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: 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 -✓✓ 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
UPDATE | CORRECT ANSWERS | WITH DETAILED
SOLUTIONS
• 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: 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. -✓✓ 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: 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 -✓✓ 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
