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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.

1500.

1600.

1800.

1000.

1200.

0800.

1400.

2000.

Answer and Explanation

Correct Answer : A,B,C,G,H

Choice A rationale
Measuring vital signs at 1500 is crucial because the client is diaphoretic and flushed, indicating a potential change in condition that needs monitoring.
Choice B rationale
At 1600, blood glucose was obtained, and it is essential to measure vital signs to assess the client’s response to the insulin lispro given at 1800.
Choice C rationale
At 1800, the client ate 75% of his tray, and 4 units of insulin lispro were administered. Monitoring vital signs at this time helps evaluate the client’s metabolic response.
Choice G rationale
At 1400, the client voided clear, yellow urine. Measuring vital signs at this time provides a baseline for comparison with subsequent readings.
Choice H rationale
Measuring vital signs at 2000 ensures continuous monitoring and helps detect any late changes in the client’s condition.

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Correct Answer is C

Explanation

Choice A rationale
Recording the client’s daily weight is not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.
Choice B rationale
Maintaining the client in high Fowler’s position can help with breathing but does not directly address the issue of dry mucous membranes due to mouth breathing and refusal to eat or drink.
Choice C rationale
Keeping mucous membranes moist is crucial for comfort and preventing complications such as dryness and cracking, which can lead to infections. This intervention directly addresses the client’s symptoms and promotes comfort.
Choice D rationale
Reporting any change in urine color is important but not the most immediate concern for a terminally ill client who is weak and mouth breathing. The priority is to address comfort and hydration.

A. Active bowel sounds in the lower right quadrant. B. Contraction of the left pupil when light shines in the right eye. C. Basilar lung sounds that are diminished in the left lung. D. Capillary refill of 2 seconds in the lower right foot.

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.

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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 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 in the plan of care?

Correct Answer is C

Explanation

Which assessment should the nurse document when charting by exception?

Correct Answer is C

Explanation

Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to the client about sexual activity. Which approach is best for the nurse to use?

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?

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?

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.