With Complete Solutions
A 21-year-old college football player has been in the hospital 24
hours for observation following a concussion. His BP has been
stable at 118/62, but suddenly he complains of a severe
headache and his BP is 170/94.The nurse orders vital sign
monitoring with what frequency?
Every 4 hours
Every 5 minutes
Every 8 hours
Every shift Correct Answer 2
A 35-year-old woman delivered a 9 lb 7 oz boy 24 hours ago via
cesarean section. Her vital signs were stable, pulse 74 bpm and
temperature 99° F, 4 hours ago. The UAP reports to the nurse
that this patient's pulse is now 100 bpm and her temperature is
101.8° F and she is complaining of chills. The room temperature
is 73° F. The nurse interprets the data and takes which action?
The patient is showing signs of likely infection. The nurse
verifies the vital signs and notifies the appropriate care provider.
The UAP is advised to wait one hour and repeat vital signs
measurement.
The patient is advised to take a shower to freshen up.
, The maintenance department is notified to increase the room
temperature. Correct Answer 1
A 6-year-old girl is carried into the emergency department (ED)
by her mother. The child is gasping for breath and wheezing.
The child's vital signs are respirations 30 bpm, pulse 120 bpm,
SpO2 92%, BP 90/50 mmHg. The nurse takes which actions?
Select all that apply.
Place the child in a sitting position on the bed with support for
her back.
Ask the mother for a medical history including any medications.
Call for the appropriate care provider to quickly evaluate.
Explain to the mother that the ED is very busy and to have a seat
in the waiting room with the child.
Initiate standing protocols for childhood asthmatic until the
appropriate care provider arrives. Correct Answer 1, 2, 3, 5
A recently hired UAP wants to please the busy staff nurse. The
UAP takes vital signs and records the data on all the patients
(10) on the step down coronary unit. The nurse must discuss this
action with the UAP and point out why this is not within her
scope of patient care. Which duties are strictly nursing
responsibilities?
Select all that apply.