Take full exam for free

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.

Question Solution

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

Take full exam free

View Related questions

A. Double check all dosage calculations. B. nusually large or small doses. C. Compare the medication label to the order. D. Use at least 2 client identifiers before administering a dose. E. Involve and educate clients in medication administration. F. Document all medication in the electronic record as soon as it is given.

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale

Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.

Choice B rationale

This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.

Choice C rationale

Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.

Choice D rationale

Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.

Choice E rationale

Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.

Choice F rationale

Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.

A. Administer PRN oral pain medication. B. Ask the client what is causing the grimacing. C. Monitor the client’s nonverbal behavior. D. Review the pain medications prescribed.

Correct Answer is B

Explanation

Choice A rationale

Administering PRN oral pain medication without further assessment may not be appropriate. The nurse needs to understand the cause of the grimacing before intervening with medication.

Choice B rationale

Asking the client what is causing the grimacing is the first step. This allows the nurse to gather more information and understand the client’s experience, which is essential for appropriate intervention.

Choice C rationale

Monitoring the client’s nonverbal behavior is important but should follow the initial assessment. Understanding the cause of the grimacing takes priority.

Choice D rationale

Reviewing the pain medications prescribed is a necessary step but should come after assessing the client’s current pain status and understanding the cause of the grimacing.

Free Nursing Test Bank

Correct Answer is ["A","C","D","E","F"]

Explanation

Correct Answer is B

Explanation

Quick Links

Resources

Free Nursing Test Bank

The primary nurse went on break at 1845.The covering nurse gave a second dose of insulin because of being unaware the primary nurse gave the ordered dose. Which error prevention techniques would have helped to avoid this?

Correct Answer is ["A","C","D","E","F"]

Explanation

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain, the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

A child has experienced several episodes of vomiting. After the nurse reviews the need to provide only clear liquids, the parent of the child reports making clear liquid popsicles out of flavored gelatin for the child. Which information should the nurse obtain about the popsicles?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a countertop. Which action should the nurse implement?

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in the plan of care?

What times should the nurse measure vital signs? Select all that apply.

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?

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Quick Links

Resources