NSG 3100 Exam 2
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?
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: 2. 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 (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). Cog- nitive
Level: Applying. Client Need: Health Maintenance and Promotion.
Nursing Process: Assessment. Learning Outcome: 29-4.
2. Which client meets the criteria for selection of the apical site for assess-
,ment 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
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?
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 mea-
surement 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.
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 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
5. It would be appropriate to delegate the taking of vital signs of which
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?
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: 2. 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 (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). Cog- nitive
Level: Applying. Client Need: Health Maintenance and Promotion.
Nursing Process: Assessment. Learning Outcome: 29-4.
2. Which client meets the criteria for selection of the apical site for assess-
,ment 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
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?
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 mea-
surement 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.
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 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
5. It would be appropriate to delegate the taking of vital signs of which
