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 A
Explanation
Choice A rationale
Beginning with queries that are less sensitive in nature can help establish rapport and trust with the client. This approach makes the client more comfortable and willing to disclose personal information, including details about sexual activity.
Choice B rationale
Asking queries in a vague, non-specific format may lead to confusion and incomplete information. It is important to ask clear and direct questions to obtain accurate information.
Choice C rationale
Getting the most difficult queries over with first may cause the client to feel uncomfortable and defensive, making it harder to obtain accurate information.
Choice D rationale
Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse should maintain a neutral and non-judgmental approach to encourage open communication.
Correct Answer is C
Explanation
Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of proper crutch walking technique. Proper crutch walking involves more than just equipment inspection.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not directly demonstrate an understanding of the correct crutch gait. The focus should be on the actual technique of using the crutches.
Choice C rationale
Bearing body weight on the palms of hands during the crutch gait is the correct behavior that indicates an understanding of proper crutch walking. This technique helps distribute weight appropriately and prevents strain on the underarms, which can cause nerve damage and discomfort.
Choice D rationale
Progressing to foot touchdown and weight bearing of the affected leg is not appropriate for a three-point gait, which is used when the client should not bear any weight on the affected leg. This choice indicates a misunderstanding of the correct crutch walking technique for this specific gait.