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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 A

Explanation

A. Hand hygiene, including washing hands before and after handling needles and syringes, is a fundamental component of standard precautions. It helps reduce the risk of transmitting pathogens between the client and the healthcare provider.
B. While wearing gloves is important for protecting oneself from potential exposure to bloodborne pathogens, it is part of personal protective equipment (PPE) precautions rather than standard precautions. Standard precautions primarily focus on hand hygiene and barrier precautions such as gloves, gowns, and masks when appropriate.
C. Wearing a face mask is not typically necessary for routine administration of medications, unless there is a risk of splashes or sprays of blood or body fluids. While it's important to protect mucous membranes from exposure to potentially infectious materials, the routine use of a face mask for medication administration is not a component of standard precautions.
D. This action is unsafe and does not demonstrate an understanding of standard precautions. Removing the needle before discarding the syringe increases the risk of needlestick injuries. Proper needle disposal involves keeping the needle intact with the syringe and disposing of them together in a puncture- resistant container.

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 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?

Correct Answer is A

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 is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?

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?

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

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.

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?

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.