An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

Temperature

Pulse rate

Respiratory rate

Answer and Explanation

The Correct Answer is B

A.   The reported tympanic temperature of 37.1°C (98.8°F) is within normal range.
B.   The blood pressure (BP) reading of 98/58 mm Hg indicates a relatively low diastolic pressure. Diastolic pressure is an important indicator of perfusion to vital organs, especially the coronary arteries and the brain. It's crucial to ensure that this reading is accurate.
C.   The reported pulse rate of 92/min falls within the normal range for an adult at rest.
D.   The reported respiratory rate of 18/min is within the normal range for an adult at rest.

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Correct Answer is B

Explanation

A. Using an indwelling urinary catheter should be avoided unless absolutely necessary due to the associated risks of infection and other complications. It's not the first-line intervention for managing urinary incontinence.
B. Frequent toileting, also known as scheduled toileting or prompted voiding, is an effective intervention for managing urinary incontinence in older adults with dementia. It helps prevent accidents by ensuring the client has regular opportunities to use the
bathroom.
C. Reminding the client to tell the nurse when they need to urinate can be helpful, but it may not be sufficient on its own, especially for individuals with dementia who may have difficulty recognizing or communicating their needs.
D. Using adult diapers should be considered a last resort, as it does not address the underlying issue and may not promote the client's independence or dignity.

A. Dilute each medication with 10 mL of tap water. B. Pinch the tube prior to attaching the medication syringe. C. Reattach the suction directly after administering the medication. D. Mix the three medications together prior to administering.

Correct Answer is B

Explanation

A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.

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An assistive personnel (AP) reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?

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Correct Answer is B

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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