What times should the nurse measure vital signs? Select all that apply
1500.
1600.
1800.
1000.
1200.
0800.
1400.
Correct Answer : A,B,C,D,E,F,G
Choice A rationale
1500 is a valid time for measuring vital signs as part of routine monitoring.
Choice B rationale
1600 is a valid time for measuring vital signs as part of routine monitoring.
Choice C rationale
1800 is a valid time for measuring vital signs as part of routine monitoring.
Choice D rationale
1000 is a valid time for measuring vital signs as part of routine monitoring.
Choice E rationale
1200 is a valid time for measuring vital signs as part of routine monitoring.
Choice F rationale
0800 is a valid time for measuring vital signs as part of routine monitoring.
Choice G rationale
1400 is a valid time for measuring vital signs as part of routine monitoring.
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Correct Answer is C
Explanation
Choice A rationale
Providing client-focused information is important, but it does not confirm that the client has understood the critical information. The nurse needs to ensure that the client has comprehended the instructions.
Choice B rationale
Observing the client’s body language can provide some insight into their understanding, but it is not a reliable method to confirm comprehension. The nurse needs to use a more direct approach to ensure understanding.
Choice C rationale
Asking the client for learning feedback is the most important strategy to confirm that the client is learning the critical information. This method allows the nurse to assess the client’s understanding and clarify any misconceptions. It ensures that the client has comprehended the instructions and can apply the information correctly.
Choice D rationale
Reinforcing key points with the client is important, but it does not confirm that the client has understood the critical information. The nurse needs to ensure that the client has comprehended the instructions.
Correct Answer is ["A","C","D","E","F"]
Explanation
Choice A rationale
Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.
Choice B rationale
This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.