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
Knowing how many popsicles are available is not relevant to the nurse’s assessment. The focus should be on the content and preparation of the popsicles to ensure they meet the clear liquid diet requirements.
Choice B rationale
The color and flavor of the gelatin used in the popsicles are not as important as ensuring the popsicles meet the clear liquid diet requirements. The nurse should focus on the preparation and content of the popsicles.
Choice C rationale
Ensuring the popsicles are completely frozen is important to adhere to the clear liquid diet recommendation. If the popsicles are not completely frozen, they may contain solid particles or ingredients that could worsen the child’s condition.
Choice D rationale
Whether the popsicles contain pulp or fruit is important to determine if they meet the clear liquid diet requirements. Popsicles with pulp or fruit do not qualify as clear liquids and could worsen the child’s condition.
Correct Answer is C
Explanation
Choice A rationale
Offering therapeutic support and comfort to a grieving family does not typically require the structured communication format of SBAR. This interaction is more about providing emotional support and empathy rather than conveying specific clinical information.
Choice B rationale
Obtaining clarification from a client’s healthcare power-of-attorney may involve detailed discussions, but it is not the primary context for SBAR. SBAR is designed for concise, structured communication about clinical situations.
Choice C rationale
Reporting a change in a client’s condition to the healthcare provider is the ideal scenario for using SBAR. This format ensures that critical information is communicated clearly and efficiently, which is essential for patient safety and effective clinical decision-making.
Choice D rationale
Completing discharge teaching to a client and family members involves providing comprehensive education and instructions, which is not the primary purpose of SBAR. SBAR is more suited for brief, focused communication about specific clinical issues.