NSG 3100 Exam 2 QUESTIONS AND
ANSWERS
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 addition,
UAP are not delegated to take apical pulse measurements for the client with an
irregular pulse as would be the case with the client newly started on antiarrhythmic
medication (option 3). Cognitive Level: Applying. Client Need: Health Promotion and
Maintenance. Nursing Process: Planning. Learning Outcome: 29-8.
An 85-year-old client has had a stroke resulting in right-sided facial drooping,
difficulty swallowing, and the inability to move self or maintain position unaided. The
nurse determines that which sites are most appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery✔✔Answer: 3, 4, and 5. Rationale: For this client, the nurse could
take an axillary, tympanic, or temporal artery temperature. Due to the facial drooping
and difficulty swallowing, the oral route is not recommended (option 1). Although the
rectal route could be used, it would require unnecessary moving and positioning of a
client who cannot assist, and it would not provide a significant advantage over the
other routes (option 2). Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-1.
, A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by
which one of the following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
4. Absent posterior tibial and pedal pulses✔✔Answer: 4. Rationale: The posterior
tibial and pedal pulses in the foot are considered peripheral and at least one of them
should be palpable in normal individuals. Option 1: A bounding radial pulse is more
indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are
central and not peripheral. Cognitive Level: Analyzing. Client Need: Health
Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
The nurse reports that the client has dyspnea when ambulating. The nurse is most
likely to have assessed which of the following?
1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood✔✔Answer: 3. Rationale: Dyspnea, difficult or labored
breathing, is commonly related to inadequate oxygenation. Therefore, the client is
likely to experience shortness of breath, that is, a sense that none of the breaths
provide enough oxygen and an immediate second breath is needed. Option 1:
Shallow respirations are seen in tachypnea (rapid
breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may
not occur with dyspnea. Option 4: The medical term for coughing up blood is
hemoptysis and is unrelated to dyspnea. Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Evaluation. Learning
Outcome: 29-7
When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150
mmHg: muffled sounds continuing down to 130 mmHg; soft thumping sounds
continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg; then
silence.
The nurse records the blood pressure as _____________.✔✔Answer: This blood
pressure should be recorded as 180/105/95 mmHg using the systolic/1st
diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear tapping
when deflation of the cuff begins. Phase 2 has a muffled, swishing sound. In phase
3, blood is flowing freely via an increasingly open artery; sounds are more crisp and
more intense but softer than phase 1. Phase 4 sounds become muffled and have a
soft blowing quality. In phase 5 the last sound is heard followed by silence. Cognitive
Level: Analyzing Client Need: Health Promotion and Maintenance. Nursing Process:
Assessment. Learning Outcome: 29-9.
In Figure 29-28 •, which number indicates the client's oxygen saturation as
measured by pulse oximetry? _____________✔✔Answer: 4. Rationale: The SpO2 in
this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option
2 the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and
ANSWERS
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 addition,
UAP are not delegated to take apical pulse measurements for the client with an
irregular pulse as would be the case with the client newly started on antiarrhythmic
medication (option 3). Cognitive Level: Applying. Client Need: Health Promotion and
Maintenance. Nursing Process: Planning. Learning Outcome: 29-8.
An 85-year-old client has had a stroke resulting in right-sided facial drooping,
difficulty swallowing, and the inability to move self or maintain position unaided. The
nurse determines that which sites are most appropriate for taking the temperature?
Select all that apply.
1. Oral
2. Rectal
3. Axillary
4. Tympanic
5. Temporal artery✔✔Answer: 3, 4, and 5. Rationale: For this client, the nurse could
take an axillary, tympanic, or temporal artery temperature. Due to the facial drooping
and difficulty swallowing, the oral route is not recommended (option 1). Although the
rectal route could be used, it would require unnecessary moving and positioning of a
client who cannot assist, and it would not provide a significant advantage over the
other routes (option 2). Cognitive Level: Applying. Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-1.
, A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by
which one of the following?
1. Bounding radial pulse
2. Irregular apical pulse
3. Carotid pulse stronger on the left side than the right
4. Absent posterior tibial and pedal pulses✔✔Answer: 4. Rationale: The posterior
tibial and pedal pulses in the foot are considered peripheral and at least one of them
should be palpable in normal individuals. Option 1: A bounding radial pulse is more
indicative that perfusion exists. Options 2 and 3: Apical and carotid pulses are
central and not peripheral. Cognitive Level: Analyzing. Client Need: Health
Promotion and Maintenance. Nursing Process: Diagnosing. Learning Outcome: 29-9.
The nurse reports that the client has dyspnea when ambulating. The nurse is most
likely to have assessed which of the following?
1. Shallow respirations
2. Wheezing
3. Shortness of breath
4. Coughing up blood✔✔Answer: 3. Rationale: Dyspnea, difficult or labored
breathing, is commonly related to inadequate oxygenation. Therefore, the client is
likely to experience shortness of breath, that is, a sense that none of the breaths
provide enough oxygen and an immediate second breath is needed. Option 1:
Shallow respirations are seen in tachypnea (rapid
breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may
not occur with dyspnea. Option 4: The medical term for coughing up blood is
hemoptysis and is unrelated to dyspnea. Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Evaluation. Learning
Outcome: 29-7
When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150
mmHg: muffled sounds continuing down to 130 mmHg; soft thumping sounds
continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg; then
silence.
The nurse records the blood pressure as _____________.✔✔Answer: This blood
pressure should be recorded as 180/105/95 mmHg using the systolic/1st
diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a clear tapping
when deflation of the cuff begins. Phase 2 has a muffled, swishing sound. In phase
3, blood is flowing freely via an increasingly open artery; sounds are more crisp and
more intense but softer than phase 1. Phase 4 sounds become muffled and have a
soft blowing quality. In phase 5 the last sound is heard followed by silence. Cognitive
Level: Analyzing Client Need: Health Promotion and Maintenance. Nursing Process:
Assessment. Learning Outcome: 29-9.
In Figure 29-28 •, which number indicates the client's oxygen saturation as
measured by pulse oximetry? _____________✔✔Answer: 4. Rationale: The SpO2 in
this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option
2 the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and
