NSG 3100 Exam 1, 2, 3, 4, Questions and Answers (2023 / 2024) (Verified Answers)

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NSG 3100 Exam 1 – 4
NSG 3100 Exam 1

1. What is the least effective decision making process >>> establishing
   assump-tions
2. what does the trial-and-error method of problem solving lack >>>exactness
3. The research process of problem solving is >>> most effective when
   used byexperienced nurses
4. why is the nursing process method used in nursing >>> it creates
   interaction between client and nurse, used to set healthcare needs and goals and
   plans, andworks well in all environments

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5. what does critical thinking allow nurses to do during emergencies >>>
   recog-nize important cues
6. child cannot grasp the mechanics behind a spirometer so the nurse uses
   balloons and jar of bubbles instead, what does this represent >>> creativity andcritical thinking
7. what does it mean when a nurse has a feeling of something going wrong
   or happening >>> intuition
8. a nurse observes a gsw patient and assumes the client is at an increased
   risk for hypovolemic shock after observing the blood spurting out of the
   wound. what is this an example of >>> inductive reasoning
9. while attending a nursing educator conference a nursing instructor obtains information about the use of concept maps and pathways. the instructor returns to work and uses these techniques, what does this show? >>>
   creat-ing an environment that supports critical thinking

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10. what is the definition of the nursing process >>> systematic rational
    method ofplanning and providing individualized nursing care
11. how are nursing cognitive skills learned >>> through reading and
    applyinghealth related literature
12. what nursing process phase identified the most current scope and standards of nursing practice thats not recognized by the NCLEX >>>
    outcomes identifications and diagnosis
13. during the interview phase, what will the nurse consider may have a
    cultural implication? >>> physical distance between the nurse and client and
    seatingarrangement
14. what is an example of an open-ended question that the nurse may use in
    the interview process >>> how have you been feeling lately

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15. what is the name of the head to toe approach during a physical assessment >>> cephalocaudal
16. what framework is based on 11 functional health patterns and collects
    data about dysfunctional and functional behavior >>> Gordons functional
    healthpatterns
17. after health history and physical assessment, the nurse identifies discrepancies in the information. what is this process >>> validating
18. the nurse takes the clients vital signs, the nurse is performing which
    phase of the nursing process >>> assessing
19. the nurse reassesses a clients temperature 45 minutes after administering acetaminophen, this is an example of what type of assessment >>>
    ongoing
20. the nurse is measuring the drainage from a Jackson-Pratt drain. what is
    considered objective data? >>> the drainage measurement is 25 ml
    get pdf at ;https://learnexams.com/search/study?query=

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

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
   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
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 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 followed by silence. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-9.

In Figure 29-28 •, which number indicates the client’s oxygen saturation as measured by pulse oximetry? _
Answer: 4. Rationale: The SpO2 in this case is 97%. Option 1 indicates the systolic blood pressure of 121 mmHg, option 2 the mean arterial pressure of 95 mmHg, option 3 the pulse of 87 beats/min, and option 5 the diastolic blood pressure of 84 mmHg. In addition, the client’s temperature is shown. Cognitive Level: Understanding. Client Need:
Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 29-3f.

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following?

1. Eliminate the reservoir.
2. Block the portal of exit from the reservoir.
3. Block the portal of entry into the host.
4. Decrease the susceptibility of the host.
   Answer: 2. Rationale: Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other individuals. Since the carrier individual is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir (option 1). Blocking the entry into a host (option 3) or decreasing the susceptibility of the host (option 4) will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Planning. Learning Outcome: 31-9

Which is the most effective nursing action for preventing and controlling the spread of infection?

1. Thorough hand hygiene
2. Wearing gloves and masks when providing direct client care
3. Implementing appropriate isolation precautions
4. Administering broad-spectrum prophylactic antibiotics
   Answer: 1. Rationale: Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand hygiene is the most effective way to
   prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring standard precautions
   (option 2). Isolation precautions are used for clients with known communicable diseases (option 3). Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms (option 4). Cognitive Level:
   Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-8.

In caring for a client on contact precautions for a draining infected foot ulcer, which action should the nurse perform?

1. Wear a mask during dressing changes.
2. Provide disposable meal trays and silverware.
3. Follow standard precautions in all interactions with the client.
4. Use surgical aseptic technique for all direct contact with the client.
   Answer: 3. Rationale: Standard precautions include all aspects of contact precautions with the exception of placing the client in a private room. A mask is indicated when working over a sterile wound rather than an infected one (option 1). Disposable food trays are not necessary for clients with infected wounds unlikely to contaminate the client’s hands (option 2). Sterile technique (surgical asepsis) is not indicated for all contact with the client (option 4). The nurse would utilize clean technique when dressing the wound to prevent introduction of additional microbes. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-10

When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the following personal protective equipment?

1. Goggles
2. Gown
3. Surgical mask
4. Clean gloves
   Answer: 1. Rationale: Unless overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off, goggles
   may be worn repeatedly (option 1). Since gowns are at high risk for contamination, they should be used only once and then discarded or
   washed (option 2). Surgical masks (option 3) and gloves (option 4) are never washed or reused. Cognitive Level: Understanding. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 31-11b.

While applying sterile gloves (open method), the cuff of the first glove rolls under itself about 0.5 cm (1/4 in.). What is the best action for the nurse to take?

1. Remove the glove and start over with a new pair.
2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand.
3. Ask a colleague to assist by unrolling the cuff.
4. Leave the cuff rolled under.
   Answer: 4. Rationale: It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of
   the fingers and hand that will be used to perform the sterile procedure. The rolled-under portion is now contaminated and should not be unrolled by the nurse or colleague since it would then touch the remaining sterile portion of the glove (option 3). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process:
   Implementation. Learning Outcome: 31-11d.

The nurse evaluates the chart of a 65-year-old client with no apparent risk factors and concludes that which immunizations are current? Select all that apply.

1. Last tetanus booster was at age 50
2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine
5. Has not received the herpes zoster vaccine
   Answer: 2, 3, and 4. Rationale: Flu shots are recommended for all adults over age 50. Only adults at risk need to receive hepatitis B and A vaccine (note that this is different than for children). Options 1 and 5 are incorrect because all adults should receive a tetanus booster every 10 years (or sooner if injured) and adults over age 60 should receive the herpes zoster vaccination. Cognitive Level: Remembering. Client Need: Safe, Effective Care Environment. Nursing Process: Assessment. Learning Outcomes: 31-8; 31-6

A client with poor nutrition enters the hospital for treatment of a puncture wound. An appropriate nursing diagnosis would be _.
Answer: Because a malnourished client with a wound is less able to resist an infection, Risk for Infection is the most likely nursing diagnosis. Others may include Pain or Imbalanced Nutrition but they are less focused on the immediate health risk. Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Diagnosing. Learning Outcome: 31-7.

After teaching a client and family strategies to prevent infection prevention, which statement by the client would indicate effective learning has occurred?

1. “We will use antimicrobial soap and hot water to wash our hands at least three times per day.”
2. “We must wash or peel all raw fruits and vegetables
   before eating.”
3. “A wound or sore is not infected unless we see it
   draining pus.”
4. “We should not share toothbrushes but it is OK to share towels and washcloths.”
   Answer: 2. Rationale: Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled. Antimicrobial soap is not indicated for regular use and may lead to resistant organisms. Hand hygiene should occur as needed. Hot water can dry and harm skin, increasing the risk of infection (option 1). Clients should learn all the signs of inflammation and infection (e.g., redness, swelling, pain, heat) and not rely on the presence of pus to indicate this (option 3). People should not share washcloths or towels (option 4). Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcomes: 31-8; 31-5.

Which of the numbered areas is considered sterile on a person in the operating room? You may assume that all articles were sterile when applied.
Answer: 1. Rationale: Sterile objects are considered unsterile if placed lower than the waist. Only area 1 in this situation would be considered sterile. Above the neck, higher than 2 inches above the elbow, below the waist/table, and the back are all considered unsterile. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcomes: 31-1; 31-11c.

The nurse determines that a field remains sterile if which of the following conditions exist?

1. Tips of wet forceps are held upward when held in ungloved hands.
2. The field was set up 1 hour before the procedure.
3. Sterile items are 2 inches from the edge of the field.
4. The nurse reaches over the field rather than around the edges.
   Answer: 3. Rationale: All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in
   contact with unsterile areas. When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field (option 1). Fields should be established immediately before use to prevent accidental contamination when not observed closely (option 2). Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field (option 4). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 31-11c.

Your client has a Braden scale score of 17. Which is the
appropriate nursing action?

1. Assess the client again in 24 hours; the score is within
   normal limits.
2. Implement a turning schedule; the client is at increased risk of skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the client is at moderate risk of skin breakdown.
4. Request an order for a special low-air-loss bed; the client is at very high risk of skin breakdown.
   Answer: 2. Rationale: A score ranging from 15 to 18 is considered at risk and a turning schedule is appropriate. Option 1 requires a score above 18 (normal and ongoing assessment is indicated). Option 3, moderate risk, for which a transparent barrier would be appropriate, is applied to persons with scores of 13 to 14. Option 4, very high risk, is assigned for those with a score of 9 or less. Cognitive Level: Applying. Client Need: Safe, Effective Care Management. Nursing Process:
   Implementation. Learning Outcome: 36-2.

Proper technique for performing a wound culture includes which of the following?

1. Cleansing the wound prior to obtaining the specimen
2. Swabbing for the specimen in the area with the largest collection of drainage
3. Removing crusts or scabs with sterile forceps and then culturing the site beneath
4. Waiting 8 hours following a dose of antibiotic to obtain the specimen
   Answer: 1. Rationale: Wound culture specimens should be obtained from a cleaned area of the wound. Microbes responsible for the infection are more likely to be found in viable tissue. Collected drainage contains old and mixed organisms. An appropriate specimen can be obtained without causing the client the discomfort of debriding. The
   nurse does not generally debride the wound to obtain a specimen. Once systemic antibiotics have been begun, the interval following a dose will not significantly affect the concentration of wound organisms. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-10.

A client has a pressure ulcer with a shallow, partial skin
thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?

1. Alginate
2. Dry gauze
3. Hydrocolloid
4. No dressing is indicated
   Answer: 3. Rationale: Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to new granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing. Cognitive Level: Applying. Client Need: Physiological Integrity. Nursing Process: Implementation. Learning Outcome: 36-11

Thirty (30) minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains the following to the client:

1. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the desired one (dilation).
2. It will be acceptable to leave the pad in place if the
   temperature is reduced.
3. It will be acceptable to leave the pad in place for another
   30 minutes if the site appears satisfactory when assessed.
4. It will be acceptable to leave the pad in place as long as it is moist heat
   Answer: 1. Rationale: The heating pad needs to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect, resulting in vasoconstriction. Lowering the temperature, but still delivering heat—dry or moist—will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 36-14

Which statement, if made by the client or family member, would indicate the need for further teaching?

1. “If a skin area gets red but then the red goes away after turning, I should report it to the nurse.”
2. “Putting foam pads under my heels or other bony areas can help decrease pressure.”
3. “If my father cannot turn himself in bed, I should help him change position every 4 hours.”
4. “The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.”
   Answer: 3. Rationale: Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires further teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be
   correct to use a foam pad to help relieve pressure. Cognitive Level: Analyzing. Client Need: Physiological Integrity. Nursing Process: Evaluation. Learning Outcome: 36-10.

Your client is only comfortable lying on the right or left side (not non the back or stomach). List four potential sites of pressure ulcers you must assess.
1.
2.
3.
4.
Answer: Potential pressure ulcer sites for side-lying clients include ankles, knees, trochanters, ilia, shoulders, and ears. These are important areas to assess. Other answers may also be correct. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 36-8.

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is

1. Risk for Impaired Skin Integrity.
2. Impaired Skin Integrity.
3. Impaired Tissue Integrity.
4. Risk for Infection.
   Answer: 2. Rationale: This client has an actual impairment of the integrity of the skin due to the rash and the scratching so is no longer “at risk.” Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected. Cognitive Level:
   Analyzing. Client Need: Physiological Integrity. Nursing Process: Diagnosing. Learning Outcome: 36-9.

Which of the following are primary risk factors for pressure ulcers? Select all that apply.

1. Low-protein diet
2. Insomnia
3. Lengthy surgical procedures
4. Fever
5. Sleeping on a waterbed
   Answer: 1, 3, and 4. Rationale: Risk factors for pressure ulcers include low-protein diet, lengthy surgical procedures, and fever. Protein is
   needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on
   bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever
   could impair circulation and skin integrity. Insomnia (option 5) would generally involve restless sleeping, which transfers pressure to different
   parts of the body and would reduce the chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular
   mattress and, thus, actually reduces the chances of skin breakdown. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 36-1.

Which of the following items are used to perform wound irrigation? Select all that apply.

1. Clean gloves
2. Sterile gloves
3. Refrigerated irrigating solution
4. 60-mL syringe
5. Forceps
   Answer: 1, 2, and 4. Rationale: To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be room or body temperature—certainly not refrigerated. Forceps may be used to remove or apply a dressing but are not required for irrigation.
   Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process: Planning. Learning Outcome: 36-13b

Which of the following indicates proper use of a triangle arm sling?

1. The elbow is kept flexed at 908 or more.
2. The knot is placed on either side of the vertebrae of the neck.
3. The sling extends to just proximal of the hand.
4. The sling is removed every 2 hours to check for circulation and skin integrity.
   Answer: 2. Rationale: The knot of the triangle sling must be kept off the spinal processes because this would be uncomfortable and put unnecessary pressure on the vertebrae. The elbow should be flexed slightly less than 80° (not >90° as in option 1) so the hand is above the elbow to prevent dependent swelling. The sling must extend past
   the wrist in order to support the hand. Although the sling must be removed to check for circulation and skin integrity, every 2 hours (option 4) is unnecessarily frequent and impractical. Cognitive Level: Remembering. Client Need: Physiological Integrity. Nursing Process:
   Evaluation. Learning Outcome: 36-13c.