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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.

1500.

1600.

1800.

1000.

1200.

0800.

1400.

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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A. Send an email to facility administrators reporting the action. B. Dispose of the copies and continue with client care assignments. C. Warn the colleague that copying health information is unlawful. D. Communicate the colleague’s activities to the unit charge nurse.

Correct Answer is D

Explanation

Choice A rationale

While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.

Choice B rationale

Reporting the colleague’s actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.

Choice C rationale

Disposing of the copies may prevent further unauthorized access to patient information, but it does not address the issue of the colleague’s inappropriate handling of the records. It’s essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

A. Expel the air in the prefilled syringe prior to injection. B. Rotate injections between the abdomen and gluteal areas. C. Massage the injection site to increase absorption. D. Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus.

Correct Answer is D

Explanation

Choice A rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for low molecular weight heparin (LMWH) administration. The air bubble in the prefilled syringe helps ensure the entire dose is delivered and prevents leakage of the medication. Removing the air bubble can lead to an incomplete dose and reduced efficacy of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for LMWH administration. The preferred site for LMWH injections is the abdominal area, specifically at least 2 inches (5.1 cm) from the umbilicus. This site provides better absorption and reduces the risk of complications such as hematoma formation.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH administration. Massaging the site can cause bruising and hematoma formation, which can be painful and may affect the absorption of the medication. It is important to avoid massaging the injection site to minimize these risks.

Choice D rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct instruction for LMWH administration. This site provides optimal absorption and reduces the risk of complications. The abdominal area has a good blood supply, which helps in the effective absorption of the medication. Additionally, injecting at least 2 inches (5.1 cm) from the umbilicus helps avoid the umbilical area, which is more prone to bruising and discomfort.

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Correct Answer is D

Explanation

Correct Answer is D

Explanation

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