you have taken the vital signs for your patient they are normal for the patient what should you do next
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Nursing Elites

NCLEX-RN

NCLEX RN Exam Prep

1. After taking the vital signs for your patient and finding them to be normal, what should you do next?

Correct answer: D

Rationale: After assessing and finding that the vital signs are normal for the patient, the appropriate action would be to document them on the graphic VS form. This form is used to track and record vital sign measurements accurately and consistently. Reporting the normal vital signs to the doctor is not necessary unless there are concerning trends or deviations. Writing the vital signs on a scrap piece of paper is not recommended as it may not be an official or reliable record. Calling the family members is unrelated to the process of documenting and tracking vital signs for the patient.

2. During a work shift, how can a nurse best demonstrate the dynamic nature of the nursing process?

Correct answer: D

Rationale: The nursing process is dynamic as it involves adapting to the changing health status of the client. Rapidly resetting priorities for client care based on changes in the client's condition exemplifies this dynamic nature by responding promptly to evolving circumstances. Collaborating with the client to establish healthcare goals (Option A), reviewing the client's medical record history (Option B), and explaining the purpose of administered medications to the client (Option C) are all essential nursing actions but do not directly showcase the dynamic nature of the nursing process.

3. When examining an infant, which area should the nurse examine first?

Correct answer: D

Rationale: When examining an infant, the nurse should start by examining the least-distressing areas first before moving on to more invasive areas. The abdomen is typically the least distressing area to examine, so it should be assessed first. Examining the eye, ear, nose, and throat are considered more invasive and should be saved for last. Therefore, the correct choice is to examine the abdomen first to ensure a comfortable and less distressing examination process for the infant. Choices A, B, and C (Ear, Nose, Throat) are more invasive areas and should be examined after the abdomen.

4. A patient suffering from hyperglycemia would be experiencing:

Correct answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.

5. A healthcare professional is employed at a district health department and must spend several hours each day sitting at a desk. Which principle of ergonomics will most likely help them to reduce the risk of injury or pain in this situation?

Correct answer: A

Rationale: When sitting for prolonged periods, it is important to adjust the height of the chair so that the legs are bent at the hips at a 90-degree angle. This position helps to reduce pressure on the back, legs, and feet, promoting better posture and reducing muscle fatigue. Standing up and moving around at least once every hour is crucial to support circulation and prevent stiffness. Maintaining the position of the computer monitor just below eye level helps reduce strain on the neck and eyes. Resting wrists on the edge of the desk while typing can lead to wrist strain and discomfort, so it is not an ergonomic recommendation for prolonged desk work.

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