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What times should the nurse measure vital signs? Select all that apply

1500.

1600.

1800.

1000.

1200.

0800.

1400.

Question Solution

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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A. Offering therapeutic support and comfort to a grieving family. B. Obtaining clarification from a client’s healthcare power-of-attorney. C. Reporting a change in a client’s condition to the healthcare provider. D. Completing discharge teaching to a client and family members.

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.

A. Ensure bevel of the needle is pointing up. B. Massage the site gently after injection. C. Hold the syringe perpendicular to the skin. D. Select upper arm as the injection site.

Correct Answer is A

Explanation

Choice A rationale

Ensuring the bevel of the needle is pointing up is crucial when administering an intradermal injection. This technique allows the medication to be deposited just below the surface of the skin, creating a small bleb or wheal. This is important for the proper absorption and effectiveness of the medication.

Choice B rationale

Massaging the site gently after injection is not recommended for intradermal injections. Massaging can cause the medication to spread into the subcutaneous tissue, which can affect the accuracy of the test results or the effectiveness of the medication.

Choice C rationale

Holding the syringe perpendicular to the skin is not appropriate for intradermal injections. Intradermal injections should be administered at a 5 to 15-degree angle to ensure the medication is deposited just below the surface of the skin.

Choice D rationale

Selecting the upper arm as the injection site is not the best practice for intradermal injections. The preferred sites for intradermal injections are the inner surface of the forearm and the upper back below the scapula.

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What times should the nurse measure vital signs? Select all that apply

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Correct Answer is C

Explanation

Correct Answer is A

Explanation

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Take full exam for free What times should the nurse measure vital signs? Select all that apply

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The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Correct Answer is C

Explanation

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

Correct Answer is A

Explanation

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What times should the nurse measure vital signs? Select all that apply