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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure accurate readings. Incorrect placement can lead to false low oxygen saturation readings.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, it is not the immediate first step.
Choice C rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient.
Choice D rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia.
Correct Answer is ["A","B","C","G","H"]
Explanation
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.