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
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.
Correct Answer is C
Explanation
Choice A rationale
Removing dentures or other oral appliances may help prevent airway obstruction but is not the most critical intervention for a client with severe obstructive sleep apnea (OSA).
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention to maintain airway patency and prevent respiratory compromise in a client with severe obstructive sleep apnea (OSA).
Choice D rationale
Putting and locking the side rails in place is important for safety but does not directly address the airway management needs of a client with severe obstructive sleep apnea (OSA).