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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. Place the client on contact precautions. B. Start a high-fiber diet. C. Administer an oral steroid. D. Make the client NPO.

Correct Answer is D

Explanation

Choice A rationale

Placing the client on contact precautions is not necessary for a blood glucose result of 104 mg/dL. Contact precautions are used to prevent the spread of infectious agents, not for managing blood glucose levels.

Choice B rationale

Starting a high-fiber diet is not indicated for a blood glucose result within the normal range. While a high-fiber diet can help manage blood glucose levels, it is not necessary for a result of 104 mg/dL56.

Choice C rationale

Administering an oral steroid is not appropriate for managing a blood glucose result of 104 mg/dL. Steroids can actually increase blood glucose levels and are not used for this purpose.

Choice D rationale

Making the client NPO (nothing by mouth) is not necessary for a blood glucose result of 104 mg/dL. This result is within the normal range, and no immediate dietary restrictions are required.

A. 1500. B. 1600. C. 1800. D. 1000. E. 1200. F. 0800. G. 1400. H. 2000.

Correct Answer is ["A","B","C","G","H"]

Explanation

Choice A rationale

Measuring vital signs at 1500 is essential because the client has a temperature of 102°F (38.9°C) at 1400, indicating a potential infection or other condition that needs monitoring.

Choice B rationale

At 1600, it is important to measure vital signs to assess the client’s response to any interventions provided for the elevated temperature.

Choice C rationale

At 1800, continuous monitoring of vital signs helps detect any changes in the client’s condition and ensures timely intervention if needed.

Choice G rationale

Measuring vital signs at 1400 provides a baseline for comparison with subsequent readings, especially given the elevated temperature.

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 D

Explanation

Correct Answer is ["A","B","C","G","H"]

Explanation

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A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?

Correct Answer is D

Explanation

Correct Answer is ["A","B","C","G","H"]

Explanation

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