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.
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Correct Answer is D
Explanation
Choice A rationale
Placing the client on contact precautions is not necessary for a blood glucose result of 104 mg/dL. Contact precautions are used to prevent the spread of infectious agents, not for managing blood glucose levels.
Choice B rationale
Starting a high-fiber diet is not indicated for a blood glucose result within the normal range. While a high-fiber diet can help manage blood glucose levels, it is not necessary for a result of 104 mg/dL56.
Choice C rationale
Administering an oral steroid is not appropriate for managing a blood glucose result of 104 mg/dL. Steroids can actually increase blood glucose levels and are not used for this purpose.
Choice D rationale
Making the client NPO (nothing by mouth) is not necessary for a blood glucose result of 104 mg/dL. This result is within the normal range, and no immediate dietary restrictions are required.
Correct Answer is D
Explanation
Choice A rationale
While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.
Choice B rationale
Reporting the colleague’s actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.
Choice C rationale
Disposing of the copies may prevent further unauthorized access to patient information, but it does not address the issue of the colleague’s inappropriate handling of the records. It’s essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.