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What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,D,E,F,G
Rationale: Context-dependent; typically every 4 hours.
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The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
- A. Offering therapeutic support to a grieving family.
- B. Obtaining clarification from a client’s healthcare power-of-attorney.
- C. Reporting a change in a client’s condition to the healthcare provider.
- D. Completing discharge teaching to a client and family members.
Correct Answer: C
Rationale: SBAR is for clinical communication.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
A client voided clear, yellow urine.
- A. The client is dehydrated.
- B. The client has a urinary tract infection.
- C. The client has normal urine output.
- D. The client has kidney stones.
Correct Answer: C
Rationale: Clear, yellow urine indicates hydration.
What times should the nurse measure vital signs? Select all that apply.
- A. 1500
- B. 1600
- C. 1800
- D. 1000
- E. 1200
Correct Answer: A,B,C,G,H
Rationale: Times align with clinical changes.
The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?
- A. Expel the air in the prefilled syringe prior to injection.
- B. Rotate injections between the abdomen and gluteal areas.
- C. Massage the injection site to increase absorption.
- D. Inject in the abdominal area at least 2 inches from the umbilicus.
Correct Answer: D
Rationale: Abdominal site ensures absorption.