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

 

Choice A rationale

This outcome statement focuses on the client’s ability to perform a specific task related to ostomy care. While it’s important for clients with a colostomy to learn how to change their ostomy bag, in the context of this scenario, where the client has developed hyperglycemia requiring insulin injections, the priority lies in managing their diabetes and adhering to the medication regimen. Therefore, while ostomy care is important, it may not be the most immediate concern.

Choice B rationale

This outcome statement indicates the client’s attempt to self-administer insulin but inability to perform the injection. While it’s important for clients to be able to self-administer insulin, the emphasis in this scenario should be on ensuring that the client adheres to the medication regimen, rather than focusing solely on their ability to self-administer insulin immediately after discharge. Therefore, while self-administration of insulin is relevant, it may not be the most immediate priority in the postoperative plan of care.

Choice C rationale

This outcome statement focuses on monitoring the client’s respiratory status by auscultating breath sounds at regular intervals. While respiratory assessment is important, especially postoperatively, it may not directly address the client’s primary health concern in this scenario, which is managing hyperglycemia and insulin administration.

Choice D rationale

This outcome statement directly addresses the client’s need to manage their hyperglycemia by adhering to the prescribed insulin regimen. Given that the client has developed hyperglycemia requiring insulin injections, ensuring medication adherence is crucial for controlling blood sugar levels and preventing complications associated with uncontrolled diabetes. This choice aligns with the client’s health needs and goals following the surgical procedure and the development of hyperglycemia.

Choice A rationale

Measuring vital signs at 0800 is a standard practice in many healthcare settings to establish a baseline for the day.

Choice B rationale

Measuring vital signs at 1000 is not typically a standard time unless there is a specific clinical indication.

Choice C rationale

Measuring vital signs at 1200 helps monitor the client’s status around midday and can be important for assessing the effects of morning medications or treatments.

Choice D rationale

Measuring vital signs at 1400 is not typically a standard time unless there is a specific clinical indication.

Choice E rationale

Measuring vital signs at 1600 helps monitor the client’s status in the afternoon and can be important for assessing the effects of afternoon medications or treatments.

Choice F rationale

Measuring vital signs at 1800 is not typically a standard time unless there is a specific clinical indication.

Choice G rationale

Measuring vital signs at 2000 helps monitor the client’s status in the evening and can be important for assessing the effects of evening medications or treatments.