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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.

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A. Gives the client a hug and says, “It’s okay to cry when you are sad.”. B. While touching the client’s forearm, asks, “Would you like to talk about it?” C. “I’m sorry to disturb you at a difficult time.This can wait until later.”. D. “This is a bad time.I can see you are upset. I can come back later.”.v

Correct Answer is B

Explanation

Choice A rationale

Giving the client a hug may not be appropriate in a professional setting and could be perceived as crossing personal boundaries.

Choice B rationale

While touching the client’s forearm, asking “Would you like to talk about it?” is a compassionate and supportive response. It shows empathy and provides the client with an opportunity to express their feelings.

Choice C rationale

Apologizing for disturbing the client and offering to wait until later may not address the client’s immediate emotional needs.

Choice D rationale

Stating that it is a bad time and offering to come back later may not provide the client with the support they need in the moment.

A. Self-care deficit. B. Impaired physical mobility. C. Risk for infection. D. Risk for impaired skin integrity.

Correct Answer is D

Explanation

Choice A rationale

While a self-care deficit may be a concern for clients with neuropathy, it is not the primary issue related to foot care. The priority is to prevent skin breakdown and injuries that can lead to more serious complications.

Choice B rationale

Impaired physical mobility is a common issue for clients with neuropathy, but it is not the primary concern for foot care. The focus should be on preventing skin breakdown and injuries.

Choice C rationale

Risk for infection is an important consideration, but it is secondary to the risk of impaired skin integrity. Preventing skin breakdown and injuries is the first step in reducing the risk of infection.

Choice D rationale

Risk for impaired skin integrity is the priority for promoting foot care in clients with neuropathy. Neuropathy can compromise the ability to detect injuries or wounds on the feet, leading to unnoticed wounds that can become infected and cause serious complications.
Preventing skin breakdown and injuries is crucial for maintaining foot health.

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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Correct Answer is B

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Correct Answer is D

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