NSG 3100 Exam 2 Practice Questions And Correct
Answers With Complete Solutions And Rationale.
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). Cognitive Level: Applying. Client Need: Health
Maintenance and Promotion. Nursing Process: Assessment. Learning
Outcome: 29-4.
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
1|Page
,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
2|Page
,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
3|Page
, 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
4|Page
Answers With Complete Solutions And Rationale.
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). Cognitive Level: Applying. Client Need: Health
Maintenance and Promotion. Nursing Process: Assessment. Learning
Outcome: 29-4.
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
1|Page
,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
2|Page
,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
3|Page
, 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
4|Page
