Patient Data
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.
1400
1200
1800
1600
0800
2000
1500
Correct Answer : B,D,E,F,G
The order is vital signs to be taken every 4 hours
Additional vital signs should be document when the client’s status changes like the diaphoresis seen at 1500 as this could signify a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"I'm sorry, but your child's medical Information is none of your business."This response is confrontational and dismissive, and it doesn't effectively address the parents' concerns. It's important to maintain professionalism and respect even in challenging situations.
"I can only give medical Information to your child because they are legally an adult."This response respects the minor's emancipated status and acknowledges that, legally, the nurse can only disclose medical information to the emancipated minor themselves. It upholds the principles of patient confidentiality and autonomy while also providing clear and accurate information to the parents about their limitations regarding access to their child's medical information.
"The healthcare provider will share this information with you," could potentially mislead the parents because it implies that the healthcare provider will provide them with the information directly. However, if the minor is legally emancipated, the healthcare provider would still be bound by confidentiality laws and would only be able to disclose information to the minor themselves unless there are extenuating circumstances or legal exceptions.
I can give you those results as soon as I get them back from the laboratory."While this response offers to provide information, it doesn't address the issue of confidentiality or the parents' role in receiving the information. It's also not accurate to promise the results directly without involving the healthcare provider, who is responsible for interpreting and discussing the results with the patient and family.
Correct Answer is C
Explanation
C. Demonstrate proper securing of the restraints is the most important action because it educates the UAP and prevents potential complications such as injury, infection, or circulation impairment.
A. Ensure that the restraints are not too tight is an important action, but it is not enough to address the issue of improper securing of the restraints. The nurse should also teach the UAP how to secure the restraints correctly and safely.
B. Complete an adverse occurrence/incident report is not the most important action because it does not correct the immediate problem or prevent harm to the client.
D. Initiate the facility’s restraint flow sheet is an important action, but it is not urgent or critical in this situation. The nurse should document and monitor the use of restraints according to the facility’s policy, but only after ensuring that they are applied correctly and appropriately.
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