Exam 2: NSG3100 / NSG 3100 (Latest Update)
Fundamental Concepts & Skills for Nursing Practice I |
Questions and Verified Answers | 100% Correct | Grade A -
Galen
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 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 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
4. Tympanic
5. Temporal artery - ANSWER 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 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 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 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
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