A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?
Place the client on contact precautions.
Start a high-fiber diet.
Administer an oral steroid.
Make the client NPO.
The Correct Answer is D
Choice A rationale
Placing the client on contact precautions is not indicated based on the provided orders. Contact precautions are typically used for infections that are spread by direct or indirect contact, such as MRSA or C. difficile. The orders do not suggest the presence of such an infection.
Choice B rationale
Starting a high-fiber diet is not indicated. The client is already on a regular diet, and there is no mention of conditions that would necessitate a high-fiber diet, such as constipation or diverticulosis.
Choice C rationale
Administering an oral steroid is not indicated. The orders include Cefazolin, an antibiotic, and Metformin, an antidiabetic medication. There is no indication for an oral steroid, which is typically used for inflammatory conditions or autoimmune diseases.
Choice D rationale
Making the client NPO (nothing by mouth) is the correct action. This is likely due to the need for accurate blood glucose monitoring and the administration of IV antibiotics. Being NPO ensures that the client does not eat or drink anything that could interfere with these treatments.
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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
A radial pulse volume of 3+ indicates a strong pulse, which should not interfere with the accuracy of a pulse oximeter reading.
Correct Answer is ["A","B","C","G","H"]
Explanation
Choice A rationale
Measuring vital signs at 1500 is crucial because the client is diaphoretic and flushed, indicating a potential change in condition that needs monitoring.
Choice B rationale
At 1600, blood glucose was obtained, and it is essential to measure vital signs to assess the client’s response to the insulin lispro given at 1800.
Choice C rationale
At 1800, the client ate 75% of his tray, and 4 units of insulin lispro were administered. Monitoring vital signs at this time helps evaluate the client’s metabolic response.
Choice G rationale
At 1400, the client voided clear, yellow urine. Measuring vital signs at this time provides a baseline for comparison with subsequent readings.
Choice H rationale
Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.