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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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is []

Explanation

Pressure sores are divided into different stages:

Stage 1= Intact skin with non-blanchable redness over a localized area

Stage 2= Partial thickness loss of dermis, shallow open ulcer with a pink base

Stage 3= Full thickness ulcer but tendons, muscles and bone are not exposed

Stage 4- Full thickness wound with exposed tendons, muscle and bone

Unstageable-Full thickness tissue loss with the base covered with an eschar or yellow, gray or brown tissue

The client already has a pressure sore that requires cleaning to remove any tissue debris that may act as nidus for infection, placing a hydrocolloid dressing protects and debrides the wound to promote healing Monitoring skin integrity is key to ensure no other pressure sores develop.

Nutritional status determines the risk of developing pressure injury and the chances of wound healing.

A. Allows 30 minutes of rest before feeding B. Places food on the unaffected side of the mouth. C. Raises the head of the bed to 60 degrees. D. Positions the head with the chin tilted slightly downward.

Correct Answer is A

Explanation

A. This is incorrect because it’s generally important to avoid long periods of rest before feeding. The client should be well-rested, but allowing 30 minutes specifically as a rest period before feeding is not a standard practice and may not align with the client's needs or feeding protocols.

B.This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.
C. Elevating the head of the bed to at least 30 to 45 degrees is recommended during feeding to reduce the risk of aspiration.
D. Tilting the chin slightly downward helps close the airway and reduces the risk of aspiration during swallowing.

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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

Correct Answer is []

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?

Correct Answer is A

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which type of exercises the client needs, two actions the nurse should take to facilitate the exercises, and two parameters the nurse should monitor to assess the client's progress.

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

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?

The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

The nurse is assessing a client who reports a 3 day history of vomiting and diarrhea and experiencing difficulty in tolerating oral fluids. Which urine specific gravity value would the nurse expect to see on initial testing? Reference Range: Urine Specific Gravity [1.005 to 1.03]

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

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.