Patient Data

Exhibits

At 2000, the unlicensed assistive personnel (UAP) reported the client's vital signs as a temperature of 102.1° F (38.9° C) orally, a heart rate of 62 beats/minute, respirations of 19 breaths/minute, and a blood pressure of 124/68 mm Hg.

Which action(s) should the nurse take? Select all that apply

Attach the client to a cardiorespiratory monitor to measure the respiratory rate

Assure that the blood pressure cuff is the right size

Alert the healthcare provider once the abnormal finding is confirmed

Retake the temperature orally

Reassess the blood pressure

Measure the heart rate for a full 60 seconds

Answer and Explanation

Correct Answer : C,D,F

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.

B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.

C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.

D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.

E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.

F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Measuring urine output is important for monitoring fluid status but does not address the immediate issue of increasing thirst as a sign of DKA.

B. Administering a dose of regular insulin as prescribed is crucial to manage elevated blood glucose levels and prevent or treat DKA.

C. Resuming normal physical activity is not recommended until DKA is managed and blood glucose levels are stabilized.

D. Drinking electrolyte fluids may help with hydration but is not a direct treatment for DKA; insulin therapy is essential to address the underlying issue.

A. Mix the next dose with food. B. Withhold this dose. C. Give another dose. D. Administer a half dose now.

Correct Answer is B

Explanation

A. Mixing the dose with food is not recommended as it might affect the absorption of the medication and does not address the immediate situation.

B. Withholding the dose is appropriate because it is uncertain how much of the medication was absorbed. Administering another dose could lead to toxicity.

C. Giving another dose without knowing how much was absorbed could cause an overdose.

D. Administering a half dose now is not recommended because the exact amount absorbed is unknown, risking either underdose or overdose.

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Nursing Test Bank

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