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

 

Choice A rationale

Having the client demonstrate prescribed wound care is the most effective method to evaluate the client’s understanding of self-care at home. This approach allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide immediate feedback and clarification as needed. Demonstration ensures that the client can correctly follow the wound care instructions, which is crucial for proper healing and preventing complications.

Choice B rationale

Asking the client if they understand after each instruction may not be effective, especially if the client is not comfortable expressing confusion or misunderstanding. This method relies on the client’s verbal confirmation, which may not accurately reflect their ability to perform the wound care tasks correctly.

Choice C rationale

Having an interpreter repeat the wound care instructions can help bridge the language barrier, but it does not allow for direct observation of the client’s ability to perform the necessary tasks. While the interpreter can ensure that the client understands the instructions, it does not provide the nurse with a way to assess the client’s practical skills.

Choice D rationale

Providing written instructions in the client’s native language can be helpful, but it does not allow the nurse to directly evaluate the client’s understanding and ability to perform the wound care tasks. Written instructions alone may not be sufficient for clients who have limited literacy or who may have difficulty following written directions.

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.