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

 

A.

1500.

B.

1600.

C.

1800.

D.

1000.

E.

1200.

F.

0800.

G.

1400.

Question Solution

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 D

Explanation

Choice A rationale

Placing the client on contact precautions is not necessary for a blood glucose result of 104 mg/dL. Contact precautions are used to prevent the spread of infectious agents, not for managing blood glucose levels.

Choice B rationale

Starting a high-fiber diet is not indicated for a blood glucose result within the normal range. While a high-fiber diet can help manage blood glucose levels, it is not necessary for a result of 104 mg/dL56.

Choice C rationale

Administering an oral steroid is not appropriate for managing a blood glucose result of 104 mg/dL. Steroids can actually increase blood glucose levels and are not used for this purpose.

Choice D rationale

Making the client NPO (nothing by mouth) is not necessary for a blood glucose result of 104 mg/dL. This result is within the normal range, and no immediate dietary restrictions are required.

Correct Answer is C

Explanation

Choice A rationale

Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.

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 because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.

Choice D rationale

Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.

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