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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.

 

A.

1500.

B.

1600.

C.

1800.

D.

1000.

E.

1200.

F.

0800.

G.

1400.

H.

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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Correct Answer is B

Explanation

Choice A rationale

Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.

Choice B rationale

Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.

Choice C rationale

Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.

Choice D rationale

Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.

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.

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