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 C
Explanation
Choice A rationale
Wearing gloves to dispose of the needle and syringe is a good practice to prevent needlestick injuries and contamination. However, it is not the primary action that indicates an understanding of standard precautions. Standard precautions emphasize hand hygiene as the most critical step in preventing infection transmission.
Choice B rationale
Donning a face mask before administering the medication is not necessary for standard precautions in home settings. Face masks are typically used in healthcare settings to prevent the spread of respiratory infections, but they are not required for routine medication administration at home.
Choice C rationale
Washing hands before handling the needle and syringe is a fundamental aspect of standard precautions. Hand hygiene is the most effective way to prevent the spread of infections and is a critical step in ensuring safe injection practices.
Choice D rationale
Removing the needle before discarding used syringes is not recommended. The entire needle and syringe should be disposed of in a sharps container to prevent needlestick injuries and contamination.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Encouraging increased fluid intake and measuring urinary output every 8 hours is not directly related to managing chronic pain. This intervention is more relevant for clients with conditions affecting fluid balance or renal function.
Choice B rationale
Providing comfort measures such as topical warm application and tactile massage can help alleviate chronic pain by promoting relaxation and improving blood circulation. These non- pharmacological interventions can be effective in managing pain and enhancing the client’s comfort.
Choice C rationale
Determining the client’s objective measure of pain using a numerical pain scale is essential for assessing the severity of pain and evaluating the effectiveness of pain management interventions. Accurate pain assessment is crucial for developing an appropriate plan of care.
Choice D rationale
Assisting the client to ambulate as much as possible during waking hours may not be feasible for clients with severe chronic pain. While physical activity is important, it should be balanced with the client’s pain levels and overall condition.
Choice E rationale
Implementing a 24-hour schedule of routine administration of prescribed analgesics ensures consistent pain relief and prevents breakthrough pain. Regular administration of analgesics is a key component of effectivepain management for clientswithchronic pain.