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 B
Explanation
Choice A rationale
Sending the UAP to be fitted for a particulate filter mask is unnecessary for droplet precautions. Particulate filter masks, such as N95 respirators, are required for airborne precautions, not droplet precautions.
Choice B rationale
Instructing the UAP that a standard face mask is sufficient is correct. Droplet precautions require a standard surgical mask to prevent the transmission of infections like bacterial meningitis. This allows the UAP to safely provide care without the need for a particulate filter mask.
Choice C rationale
Determining which staff members have fitted particulate filter masks is unnecessary for droplet precautions. This action is more relevant for airborne precautions, where particulate filter masks are required.
Choice D rationale
Advising the UAP to wear a standard face mask to obtain vital signs and then get fitted for a filter mask before providing personal care is incorrect. A standard face mask is sufficient for all aspects of care under droplet precautions.
Correct Answer is C
Explanation
Choice A rationale
Active bowel sounds in the lower right quadrant are a normal finding and do not deviate from the established norm or expected outcome. Therefore, they do not need to be documented when charting by exception.
Choice B rationale
Contraction of the left pupil when light shines in the right eye is a normal consensual pupillary response. This is an expected finding and does not need to be documented when charting by exception.
Choice C rationale
Basilar lung sounds that are diminished in the left lung are not within normal limits and deviate from the expected outcome. This abnormal finding should be documented when charting by exception.
Choice D rationale
Capillary refill of 2 seconds in the lower right foot is a normal finding and does not deviate from the established norm or expected outcome. Therefore, it does not need to be documented when charting by exception.