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
The client is dehydrated. Dehydration typically results in concentrated, dark yellow urine. Clear, yellow urine indicates that the client is well-hydrated and not dehydrated. Dehydration would cause the urine to be more concentrated and darker in color due to the reduced volume of water in the body.
Choice B rationale
The client has a urinary tract infection. A urinary tract infection (UTI) often causes urine to appear cloudy, foul-smelling, or tinged with blood. Clear, yellow urine is not indicative of a UTI. UTIs are usually associated with symptoms such as pain or burning during urination, frequent urination, and cloudy or bloody urine.
Choice C rationale
The client has normal urine output. Clear, yellow urine is a sign of normal urine output and indicates that the client is well-hydrated. Normal urine color ranges from pale yellow to amber, depending on the concentration of the urine. Clear, yellow urine suggests that the client is drinking an adequate amount of water and maintaining proper hydration.
Choice D rationale
The client has kidney stones. Kidney stones can cause urine to appear cloudy, pink, red, or brown due to the presence of blood. Clear, yellow urine is not indicative of kidney stones. Symptoms of kidney stones include severe pain in the back or side, blood in the urine, and frequent urination. Clear, yellow urine suggests that the client does not have kidney stones.
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.