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 B
Explanation
Choice A rationale
Withdrawing the medication into a syringe and labeling it with the client’s name is not necessary and could lead to errors or contamination.
Choice B rationale
Asking another nurse to witness the medication being discarded ensures proper documentation, accountability, and compliance with regulations.
Choice C rationale
Placing the vial with the remainder of the medication into a locked drawer does not address the need for proper documentation and labeling of the remaining medication.
Choice D rationale
Throwing the vial into the trash in the presence of another nurse is not appropriate as it does not ensure proper documentation, accountability, or safe storage of the remaining medication.
Correct Answer is B
Explanation
Choice A rationale
Providing a numeric pain scale helps quantify the intensity of pain but does not assess the quality of the pain. Quality refers to the characteristics and nature of the pain, which cannot be captured by a numeric scale alone.
Choice B rationale
Asking the client to describe the pain is the best approach to assess the quality of the pain. This allows the client to provide detailed information about the pain’s characteristics, such as its nature, location, and any associated symptoms.
Choice C rationale
Observing body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain’s quality. Nonverbal cues are helpful but should be supplemented with the client’s verbal description.
Choice D rationale
Identifying effective pain relief measures is important for pain management but does not directly assess the quality of the pain. This step comes after understanding the pain’s characteristics.