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Patient Data

Exhibits

Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

1400

1200

1800

1600

0800

2000

1500

Answer and Explanation

Correct Answer : B,D,E,F,G

The order is vital signs to be taken every 4 hours

Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.

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Correct Answer is D

Explanation

D. Nonverbal behavior, the nurse can gather further information about the presence and intensity of pain. This includes observing facial expressions, body movements, and any other signs of discomfort. It's important to recognize that individuals may not always verbalize their pain for various reasons, such as fear of medication side effects, concerns about being a burden, or communication barriers.
A. Reviewing the pain medications is important but it may not be the immediate priority in this scenario, as the client is currently experiencing pain-related grimacing.
B. Administering pain medication without further assessment of the client's pain or understanding the cause of the grimacing may not address the underlying issue contributing to the client's discomfort.
C. While communication with the client is important, asking about the cause of the grimacing may not provide accurate information, especially if the client is denying pain. Nonverbal cues such as grimacing suggest the presence of pain, which may not be fully acknowledged by the client.

A. Insert a rectal tube at specified intervals. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Encourage the use of incontinence briefs.

Correct Answer is B

Explanation

B. Assisting the client to a bedside commode after meals can help take advantage of the gastrocolic reflex, which typically stimulates bowel movements after eating. This timing may increase the likelihood of successful bowel evacuation and decrease the risk of soiling the bed and clothing.
A. Rectal tubes are sometimes used for bowel management in individuals with chronic fecal incontinence, but they are typically reserved for specific situations and are not commonly used as part of a routine bowel training regimen.
C. Glycerin suppositories are sometimes used to stimulate bowel movements in individuals with constipation, but they are not typically recommended as a routine intervention for managing fecal incontinence.
D. Incontinence briefs can help contain fecal soiling and minimize embarrassment associated with accidents but they do not address the underlying issues contributing to fecal incontinence.

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Patient Data Exhibits Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first

Correct Answer is D

Explanation

A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

The nurse is teaching a client about use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing. and refusing anything to eat or drink. Which intervention should the nurse include plan of care?

The nurse in a skilled nursing facility observes a colleague leaving printed electronic medical record (EMR) copies of a client unattended on a counter top. Which action should the nurse implement?

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Patient Data

Exhibits

Review H and P, nurse's notes, flow sheet, laboratory values, orders, and imaging studies. What times should the nurse measure vital signs? Select all that apply.