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
Beginning cardiopulmonary resuscitation (CPR) and calling a code would be inappropriate in this situation because the client has a signed do not resuscitate (DNR) form. A DNR order is a legal document that instructs healthcare providers not to perform CPR if the client’s heart stops or if they stop breathing. Performing CPR would go against the client’s wishes and legal rights.
Choice B rationale
Asking the unlicensed assistive personnel (UAP) to complete postmortem care is not the immediate next step. While postmortem care is necessary, the nurse must first report the client’s status to the healthcare provider to ensure proper documentation and follow-up actions.
Choice C rationale
Reporting the client’s status to the healthcare provider is the correct action. This ensures that the healthcare provider is aware of the client’s condition and can provide further instructions or documentation as needed. It is essential to follow the proper chain of command and legal protocols in such situations.
Choice D rationale
Notifying the family of the client’s death is important, but it is not the immediate next step. The nurse should first report the client’s status to the healthcare provider to ensure that all necessary medical and legal documentation is completed before contacting the family.
Correct Answer is A
Explanation
Choice A rationale
Ensuring the bevel of the needle is pointing up is crucial when administering an intradermal injection. This technique allows the medication to be deposited just below the surface of the skin, creating a small bleb or wheal. This is important for the proper absorption and effectiveness of the medication.
Choice B rationale
Massaging the site gently after injection is not recommended for intradermal injections. Massaging can cause the medication to spread into the subcutaneous tissue, which can affect the accuracy of the test results or the effectiveness of the medication.
Choice C rationale
Holding the syringe perpendicular to the skin is not appropriate for intradermal injections. Intradermal injections should be administered at a 5 to 15-degree angle to ensure the medication is deposited just below the surface of the skin.
Choice D rationale
Selecting the upper arm as the injection site is not the best practice for intradermal injections. The preferred sites for intradermal injections are the inner surface of the forearm and the upper back below the scapula.