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
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position can help with breathing but does not directly address the issue of dry mucous membranes due to mouth breathing and refusal to eat or drink.
Choice C rationale
Keeping mucous membranes moist is crucial for comfort and preventing complications such as dryness and cracking, which can lead to infections. This intervention directly addresses the client’s symptoms and promotes comfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Correct Answer is D
Explanation
Choice A rationale
While informing the colleague about the unlawful nature of copying health information is important, it may not adequately address the potential breach of patient privacy and confidentiality. Additionally, the colleague may be aware of the laws but still engage in inappropriate behavior.
Choice B rationale
Reporting the colleague’s actions to facility administrators may be necessary, but it may not be the most immediate action to take. Informing the unit charge nurse allows for more immediate intervention and resolution within the unit.
Choice C rationale
Disposing of the copies may prevent further unauthorized access to patient information, but it does not address the issue of the colleague’s inappropriate handling of the records. It’s essential to report the incident to the appropriate authority for further investigation and follow-up.
Choice D rationale
Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.