Exhibits
In the trauma unit, vital signs ordered every 4 hours are taken at 0400, 0800, 1200, 1600, 2000, and 2400.
Select the times that the nurse should do vital signs. Select all that apply.
0200
1300
1000
1600
1400
0900
0800
0500
1100
1200
Correct Answer : B,C,D,E,F,G
A. Incorrect- 0200: This is not a scheduled time for vital sign assessments every 4 hours.
B. Correct- 1300: This is 4 hours after the 0900 vital signs, following the every 4-hour schedule.
C. Correct 1000: This is 4 hours after the 0600 vital signs, following the every 4-hour schedule.
D. Correct 1600: This is 4 hours after the 1200 vital signs, following the every 4-hour schedule.
E. Correct 1400: This is 4 hours after the 1000 vital signs, following the every 4-hour schedule.
F. Correct 0900: This is the initial vital sign assessment upon admission to the trauma unit at 0100, and it's also 4 hours after the 0500 vital signs.
G. Correct 0800: This is 4 hours after the 0400 vital signs, following the every 4-hour schedule.
H. Incorrect 0500: This is 3 hours after the initial vital sign assessment at 0100. The scheduled assessments are every 4 hours, so the nexta one would be at 0900.
I. Correct 1100: This is 4 hours after the 0700 vital signs, following the every 4-hour schedule.
J. Correct 1200: This is 4 hours after the 0800 vital signs, following the every 4-hour schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:
Give the client a glass of orange juice.
A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.
Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.
Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.
Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.
Correct Answer is C
Explanation
A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information.
B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being.
C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation.
D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease.
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