NSG 3100 EXAM 2 / QUESTIONS
AND CORRECT ANSWERS
2025/2026 GRADED A+ LATEST
UPDATE (BEST FOR REVISION )
!!!
,1. The client's temperature at 8 ANSWER00 am using an oral electronic thermometeris 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 ANSWER 2. Rationale ANSWER Although the temper-ature
is slightly lower than expected for the morning, it would be best to determine theclient'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). CognitiveLevel ANSWER Applying. Client Need ANSWER Health Maintenance and
Promotion. Nursing Process ANSWERAssessment. Learning Outcome ANSWER 29-4.
2. Which client meets the criteria for selection of the apical site for assessmentof 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 ANSWER 3. Rationale ANSWER The apical
rate would confirm the rate and determine the actual cardiac rhythm for a clientwith an abnormal rhythm; a radial pulse would
only reveal the heart rate and suggestan 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 (option2). The radial pulse is appropriate for
routine postoperative vital sign checks for clients with regular pulses (option 4). Cognitive Level ANSWER
Understanding. Client Need ANSWERHealth Promotion and Maintenance. Nursing Process ANSWER Planning. Learning
Outcome ANSWER29-5
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 therespiratory 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 countrespirations.
4. Since there is no evidence of distress or urgency, postpone the mea- surement until later. ANSWER Answer
ANSWER 4. Rationale ANSWER 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 ANSWER Respirations should be measured for 30 seconds to 1 minute and
are affected by talking. Option 2 ANSWER There needs to be animportant reason for interrupting the
client. Option 3 ANSWER It is inappropriate to wait and listen to the client's conversation. Cognitive Level ANSWER
Understanding. Client Need ANSWER Health Promotion and Maintenance.Nursing Process ANSWER Planning.
Learning Outcome ANSWER 29-3d.
4. 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 bloodpressure 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 ANSWER 2. Rationale ANSWER 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 rangeof 90 mmHg will require 30 to 45
seconds. Cognitive Level ANSWER Analyzing. Client Need ANSWERHealth Promotion and Maintenance. Nursing
Process ANSWER Implementation. Learning Outcome ANSWER 29-3e
5. It would be appropriate to delegate the taking of vital signs of which clientto unlicensed assistive personnel?
1. A client being prepared for elective facial surgery with a history of stablehypertension
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 Answer ANSWER 1. Ratio- nale ANSWER
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 antiarrhythmicmedication (option 3). Cognitive Level ANSWER Applying. Client
Need ANSWER Health Promotion andMaintenance. Nursing Process ANSWER Planning. Learning Outcome ANSWER
29-8.
6. An 85-year-old client has had a stroke resulting in right-sided facial droop-ing, difficulty swallowing, and the
inability to move self or maintain position unaided.The nurse determines that which sites are most appropriate for
takingthe temperature?
AND CORRECT ANSWERS
2025/2026 GRADED A+ LATEST
UPDATE (BEST FOR REVISION )
!!!
,1. The client's temperature at 8 ANSWER00 am using an oral electronic thermometeris 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 ANSWER 2. Rationale ANSWER Although the temper-ature
is slightly lower than expected for the morning, it would be best to determine theclient'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). CognitiveLevel ANSWER Applying. Client Need ANSWER Health Maintenance and
Promotion. Nursing Process ANSWERAssessment. Learning Outcome ANSWER 29-4.
2. Which client meets the criteria for selection of the apical site for assessmentof 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 ANSWER 3. Rationale ANSWER The apical
rate would confirm the rate and determine the actual cardiac rhythm for a clientwith an abnormal rhythm; a radial pulse would
only reveal the heart rate and suggestan 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 (option2). The radial pulse is appropriate for
routine postoperative vital sign checks for clients with regular pulses (option 4). Cognitive Level ANSWER
Understanding. Client Need ANSWERHealth Promotion and Maintenance. Nursing Process ANSWER Planning. Learning
Outcome ANSWER29-5
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 therespiratory 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 countrespirations.
4. Since there is no evidence of distress or urgency, postpone the mea- surement until later. ANSWER Answer
ANSWER 4. Rationale ANSWER 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 ANSWER Respirations should be measured for 30 seconds to 1 minute and
are affected by talking. Option 2 ANSWER There needs to be animportant reason for interrupting the
client. Option 3 ANSWER It is inappropriate to wait and listen to the client's conversation. Cognitive Level ANSWER
Understanding. Client Need ANSWER Health Promotion and Maintenance.Nursing Process ANSWER Planning.
Learning Outcome ANSWER 29-3d.
4. 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 bloodpressure 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 ANSWER 2. Rationale ANSWER 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 rangeof 90 mmHg will require 30 to 45
seconds. Cognitive Level ANSWER Analyzing. Client Need ANSWERHealth Promotion and Maintenance. Nursing
Process ANSWER Implementation. Learning Outcome ANSWER 29-3e
5. It would be appropriate to delegate the taking of vital signs of which clientto unlicensed assistive personnel?
1. A client being prepared for elective facial surgery with a history of stablehypertension
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 Answer ANSWER 1. Ratio- nale ANSWER
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 antiarrhythmicmedication (option 3). Cognitive Level ANSWER Applying. Client
Need ANSWER Health Promotion andMaintenance. Nursing Process ANSWER Planning. Learning Outcome ANSWER
29-8.
6. An 85-year-old client has had a stroke resulting in right-sided facial droop-ing, difficulty swallowing, and the
inability to move self or maintain position unaided.The nurse determines that which sites are most appropriate for
takingthe temperature?
