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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.

 

A.

1500.

B.

1600.

C.

1800.

D.

1000.

E.

1200.

F.

0800.

G.

1400.

H.

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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Sending the UAP to be fitted for a particulate filter mask is unnecessary for droplet precautions. Particulate filter masks, such as N95 respirators, are required for airborne precautions, not droplet precautions.

Choice B rationale

Instructing the UAP that a standard face mask is sufficient is correct. Droplet precautions require a standard surgical mask to prevent the transmission of infections like bacterial meningitis. This allows the UAP to safely provide care without the need for a particulate filter mask.

Choice C rationale

Determining which staff members have fitted particulate filter masks is unnecessary for droplet precautions. This action is more relevant for airborne precautions, where particulate filter masks are required.

Choice D rationale

Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is incorrect. A standard face mask is sufficient for all aspects of care under droplet precautions.

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.

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