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 ["A","C","D"]
Explanation
Choice A rationale
Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.
Choice B rationale
Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.
Choice C rationale
Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.
Choice D rationale
Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.
Correct Answer is A
Explanation
Choice A rationale
Beginning with queries that are less sensitive in nature can help establish rapport and trust with the client. This approach makes the client more comfortable and willing to disclose personal information, including details about sexual activity.
Choice B rationale
Asking queries in a vague, non-specific format may lead to confusion and incomplete information. It is important to ask clear and direct questions to obtain accurate information.
Choice C rationale
Getting the most difficult queries over with first may cause the client to feel uncomfortable and defensive, making it harder to obtain accurate information.
Choice D rationale
Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse should maintain a neutral and non-judgmental approach to encourage open communication.