An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Temperature

Pulse rate

Respiratory rate

Answer and Explanation

The Correct Answer is B

A.   The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B.   The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C.   The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D.   The reported respiratory rate of 18/min is within the normal range for an adult at rest.

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Correct Answer is C

Explanation

A. Measuring the gastric residual is a common practice before administering enteral feedings. It helps to assess if the client's stomach is emptying properly and if there is any buildup of undigested formula. This is important in identifying delayed gastric emptying, which can lead to complications if not addressed.
B. To remove gastric acid that might cause dyspepsia is not the primary purpose of measuring gastric residual. The main concern is to assess the rate of stomach emptying.
C. To confirm the placement of the NG tube is typically done using other methods, such as pH testing or an X-ray. While aspirating stomach contents through the tube can help confirm placement, it is not the primary purpose of measuring gastric residual.
D. To determine the client's electrolyte balance is not related to the purpose of measuring gastric residual. Electrolyte balance is typically assessed through blood tests and clinical signs and symptoms.

A. Obtain the provider's signature within 8 hr. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record. D. Implement a recorded order message if the nurse can hear and understand it clearly. E. beat the order back to the provider.

Correct Answer is ["B","C","E"]

Explanation

A. Obtaining the provider's signature within 8 hours is not applicable to telephone orders.
This action is typically relevant to written orders.
B. Question any part of the order that is unclear or inappropriate. This helps ensure that the nurse fully understands the prescription and can catch any potential errors or discrepancies.
C. Transcribe the order into the client's health record. This step is crucial for documentation and to ensure that all members of the healthcare team have access to the prescribed treatment.
D. Implement a recorded order message if the nurse can hear and understand it clearly.
This is important to have a clear and accurate record of the provider's prescription, especially if there is any ambiguity in the verbal communication.
E. Repeating the order back to the provider is an effective method to confirm accuracy. This read-back process helps to verify that the nurse has understood the prescription correctly, reducing the potential for errors.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is C

Explanation

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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