NSG 3100–Fundamentals of Nursing | Exam
With Questions And Correct Answers
Exam
**Question 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**
**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 another
thermometer. Chart only after determining the temperature has
been measured properly .
---
,**Question 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**
**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 orthostatic changes and routine
postoperative checks .
---
**Question 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**
**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 .
---
**Question 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 blood pressure cuff to obtain an accurate reading?
A) 10-20 seconds
B) 30-45 seconds
C) 1-1.5 minutes
D) 3-3.5 minutes
, **Answer: B**
**Rationale:** If the cuff is inflated to about 30 mmHg over previous
systolic pressure, that would be 168. The cuff should be deflated at a
rate of 2 to 3 mm per second. A range of 90 mmHg will require 30 to
45 seconds .
---
**Question 5**
It would be appropriate to delegate the taking of vital signs of which
client to unlicensed assistive personnel?
A) A client being prepared for elective facial surgery with a history of
stable hypertension
B) A client receiving a blood transfusion with a history of transfusion
reactions
C) A client recently started on a new antiarrhythmic agent
D) A client who is admitted frequently with asthma attacks
**Answer: A**
**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. UAP are not
With Questions And Correct Answers
Exam
**Question 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**
**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 another
thermometer. Chart only after determining the temperature has
been measured properly .
---
,**Question 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**
**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 orthostatic changes and routine
postoperative checks .
---
**Question 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**
**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 .
---
**Question 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 blood pressure cuff to obtain an accurate reading?
A) 10-20 seconds
B) 30-45 seconds
C) 1-1.5 minutes
D) 3-3.5 minutes
, **Answer: B**
**Rationale:** If the cuff is inflated to about 30 mmHg over previous
systolic pressure, that would be 168. The cuff should be deflated at a
rate of 2 to 3 mm per second. A range of 90 mmHg will require 30 to
45 seconds .
---
**Question 5**
It would be appropriate to delegate the taking of vital signs of which
client to unlicensed assistive personnel?
A) A client being prepared for elective facial surgery with a history of
stable hypertension
B) A client receiving a blood transfusion with a history of transfusion
reactions
C) A client recently started on a new antiarrhythmic agent
D) A client who is admitted frequently with asthma attacks
**Answer: A**
**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. UAP are not
