Patient Data History and Physical Nurses’ Notes Laboratory Results Imaging Studies 1400 The client voided clear, yellow urine. 1500 The client is diaphoretic and flushed. Temperature elevated. Ibuprofen given as ordered. 1600 Flow Sheet Orders Blood glucose obtained. 1800 The client ate 75% of his tray for a total of 60 carbohydrates. 4 units of insulin lispro given. Review H and P, nurse’s notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.
1500.
1600.
1800.
1000.
1200.
0800.
1400.
2000.
Correct Answer : A,B,C,G,H
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Asking the healthcare provider for a mild sedative for bedtime may not be the best first-line approach for improving sleep. Sedatives can have side effects and may lead to dependency. Non-pharmacological interventions are generally preferred for managing sleep disturbances in older adults.
Choice B rationale
Taking an afternoon nap to make up for missed sleep can disrupt the sleep-wake cycle and make it harder to fall asleep at night. It is generally recommended to avoid napping during the day to improve nighttime sleep quality.
Choice C rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not a recommended practice for improving sleep. Alcohol can disrupt sleep patterns and lead to poor sleep quality. It is better to avoid alcohol before bedtime.
Choice D rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and improve sleep quality. Consistency in sleep schedules is a key factor in promoting healthy sleep habits.
Choice E rationale
Avoiding caffeinated beverages late in the day is important for improving sleep. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep.
Correct Answer is C
Explanation
Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The priority is to address the client’s comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position may help with breathing but does not directly address the issue of dry mucous membranes.
Choice C rationale
Keeping mucous membranes moist is crucial for the comfort of a terminally ill client who is mouth breathing and refusing anything to eat or drink. This intervention helps prevent dryness and discomfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client in this condition. The priority is to address the client’s comfort and hydration.