NSG 3100 Exam 2 Questions with Complete Solutions (Latest 2025)
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?
- Wait 15 minutes and retake it.
- Check what the client's temperature was the last time it
- Retake it using a different thermometer.
- Chart the temperature; it is normal - Correct Answers
was taken.
✅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?
- A client who is in shock
- A client whose pulse changes with body position changes
- A client with an arrhythmia 1 / 3
NSG 3100 Exam 2 Questions with Complete Solutions (Latest 2025)
- A client who had surgery less than 24 hours ago - Correct
Answers ✅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 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?
- Count the respirations during conversational pauses.
- Ask the client to end the phone call now and resume it at a
- Wait at the client's bedside until the phone call is
- Since there is no evidence of distress or urgency, postpone
later time.
completed and then count respirations.
the measurement until later. - Correct Answers ✅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 2 / 3
NSG 3100 Exam 2 Questions with Complete Solutions (Latest 2025)
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?
- 10-20 seconds
- 30-45 seconds
- 1-1.5 minutes
- 3-3.5 minutes - Correct Answers ✅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
- / 3