NSG 3100 Exam 2 2024 WITH CORRECT AND VERRIFIED ANSWERS 2025
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Course
NSG 3100
Institution
NSG 3100
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....
NSG 3100 Exam 2 2024 WITH CORRECT AND VERRIFIED ANSWERS 2025 An 85 -year-old clie nt 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 - CORRECT ANSWERS -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). C ognitive 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 radi al pulse 2. Irregular apical pulse 3. Carotid pulse stronger on the left side than the right 4. Absent posterior tibial and pedal pulses - CORRECT ANSWERS -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 pres sure 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 - CORRE CT ANSWERS -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, th e 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 - CORRECT ANSWERS -Answer: 3. Rationale: The apical rate would confirm the rate and determin e 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 c hange 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 P rocess: Planning. Learning Outcome: 29 -
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