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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

Explanation

Choice A rationale
Edema in the fingers and hands can affect the accuracy of a pulse oximeter reading. The swelling can interfere with the probe’s ability to detect the blood flow properly, leading to a falsely low oxygen saturation reading.
Choice B rationale
A capillary refill time of 2 seconds is considered normal and does not typically affect the accuracy of a pulse oximeter reading.
Choice C rationale
Blood pressure of 142/88 mm Hg, while elevated, does not directly impact the accuracy of a pulse oximeter reading.
Choice D rationale
A radial pulse volume of 3+ indicates a strong pulse, which should not interfere with the accuracy of a pulse oximeter reading.

A. Administering the medication to a client behind a closed curtain. B. Informing a client that the medication being administered is a vitamin. C. Placing a client in restraints without having a healthcare provider’s order. D. Enlisting security personnel to assist with restraining the client.

Correct Answer is B

Explanation

Choice A rationale
Administering the medication to a client behind a closed curtain may provide privacy but does not address the ethical and legal implications of administering medication without proper consent or informing the client of the medication’s true nature.
Choice B rationale
Informing a client that the medication being administered is a vitamin is deceptive and unethical. It violates the principle of informed consent, which requires that patients be fully informed about the medications they are receiving, including their purpose and potential side effects.
Choice C rationale
Placing a client in restraints without a healthcare provider’s order is a violation of patient rights and can be considered an assault. Restraints should only be used when absolutely necessary and with proper authorization to ensure the safety of the patient and staff.
Choice D rationale
Enlisting security personnel to assist with restraining the client may be necessary in some situations to ensure safety. However, it should be done following proper protocols and with the appropriate orders from a healthcare provider.

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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 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?

Correct Answer is A

Explanation

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

Correct Answer is B

Explanation

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 preparing to administer lorazepam 1.5 mg IV to an anxious preoperative client. The medication is available in a 2 mg/mL vial. Which action should the nurse perform with the remainder of the medication?

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?

A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?

A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours. Which action should the nurse take?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

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.