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NSG 3100 EXAM 2 GALEN COLLEGE LATEST REAL EXAM 2024 WITH 100 QUESTIONS AND CORRECT VERIFIED ANSWERS ALREADY GRADED A+/ NSG 3100 EXAM 2 (FUNDAMENTAL CONCEPTS & SKILLS FOR NURSING PRACTICE I)£20.39
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NSG 3100 EXAM 2 GALEN COLLEGE LATEST REAL
EXAM 2024 WITH 100 QUESTIONS AND CORRECT
VERIFIED ANSWERS ALREADY GRADED A+/ NSG
3100 EXAM 2 (FUNDAMENTAL CONCEPTS & SKILLS
FOR NURSING PRACTICE I)
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
immediate second breath is needed. Option 1: Shallow respirations are seen in
tachypnea (rapid
breathing). Option 2: Wheezing is a high-pitched breathing sound that may or may
not occur with dyspnea. Option 4: The medical term for coughing up blood is
hemoptysis and is unrelated to dyspnea. Cognitive Level: Applying. Client Need:
Health Promotion and Maintenance. Nursing Process: Evaluation. Learning
Outcome: 29-7
When auscultating the blood pressure, the nurse hears:
From 200 to 180 mmHg: silence; then: a thumping sound continuing down to 150
mmHg: muffled sounds continuing down to 130 mmHg; soft thumping sounds
continuing down to 105 mmHg; muffled sounds continuing down to 95 mmHg;
then silence.
The nurse records the blood pressure as _____________.
Answer: This blood pressure should be recorded as 180/105/95 mmHg using the
systolic/1st diastolic/2nd diastolic convention. Rationale: Phase 1 first sound is a
clear tapping when deflation of the cuff begins. Phase 2 has a muffled, swishing
sound. In phase 3, blood is flowing freely via an increasingly open artery; sounds
are more crisp and more intense but softer than phase 1. Phase 4 sounds become
muffled and have a soft blowing quality. In phase 5 the last sound is heard
pg. 1
,followed by silence. Cognitive Level: Analyzing Client Need: Health Promotion
and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-9.
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 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
The nurse is placing an indwelling catheter in a female patient. The nurse
accidentally inserts the catheter into the vagina. What is the next action for the
nurse to implement?
pg. 2
,a. Collect a urine specimen and notify the primary care provider (PCP).
b. Leave the catheter in place and insert a new catheter into the urethra.
c. Remove the catheter from the vagina and place it into the urethra.
d. Ask another nurse to attempt the catheterization of the patient.
b
Which nursing intervention would be the highest priority when caring for a patient
complaining of voiding small amounts of urine in relation to his fluid intake?
a. Placing a disposable waterproof pad on the patient's bed before he goes to sleep.
b. Documenting in the patient's electronic health record that he is complaining of
anuria.
c. Notifying the patient's primary care provider (PCP) of the need for intermittent
catherization.
d. Palpating the patient's bladder for distention before scanning for possible
retention.
d
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?
pg. 3
, 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
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
pg. 4
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