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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 ["A","C","D"]

Explanation

Choice A rationale
Decreased muscle tone, relaxed jaw muscles, and a sagging mouth are common signs that indicate a client is near death. These changes occur as the body begins to shut down and muscle control diminishes.
Choice B rationale
Clear yellow urine output is not typically associated with the end-of-life stage. As death approaches, urine output usually decreases and may become darker in color.
Choice C rationale
Altered breathing patterns, such as apnea, labored or irregular breathing, and Cheyne-Stokes respiration, are common signs that a client is nearing death. These changes in breathing patterns are due to the body’s decreasing ability to regulate respiratory function.
Choice D rationale
Congestion and increased pulmonary secretions, often referred to as the “death rattle,” are common signs that a client is near death. These noisy respirations occur as the body’s ability to clear secretions diminishes.

A. “The healthcare provider will share this information with you.”. B. “I’m sorry, but your child’s medical information is none of your business.”. C. “I can give you those results as soon as I get them back from the laboratory.”. D. “I can only give medical information to your child because they are legally an adult.”.

Correct Answer is D

Explanation

Choice A rationale
Stating that the healthcare provider will share the information does not address the legal status of the emancipated minor and may delay the communication of important information.
Choice B rationale
Telling the parents that their child’s medical information is none of their business is not respectful and does not provide a clear explanation of the legal situation.
Choice C rationale
Offering to give the results to the parents as soon as they are available does not respect the legal autonomy of the emancipated minor.
Choice D rationale
Explaining that medical information can only be given to the client because they are legally an adult is the best response. It respects the legal status of the emancipated minor and their right to make their own healthcare decisions.

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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

A 45-year-old client with breast cancer which has metastasized is receiving hospice care. The client is at home and the family is concerned about their loved one. The nurse assesses the client. Which of the following signs indicate that the client is near death?

Correct Answer is ["A","C","D"]

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client’s parents arrive and are asking querry about the client’s laboratory results.Which response is best for the nurse to provide?

Correct Answer is D

Explanation

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 client who had emergency gallbladder surgery yesterday is getting ready for discharge. The client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?

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?

Which assessment should the nurse document when charting by exception?

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

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?

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.