Upon admission to the postanesthesia care unit at 9:20 AM, the client has a temperature of 97.2 F, a pulse of 68, respirations of 12, and a blood pressure of 120/73.
You take vital signs every 10 minutes. Which of the following readings obtained at 10:10 AM would you report to the physician?
1. temperature of 98.1 F
2. pulse of 86
3. respirations of 14
4. blood pressure of 90/48
Question 2
A nurse overhears a student nurse talking about making patients' hospital beds. The nurse feels the need to intervene when the student says:
1. I must make certain the bed rails are raised on the opposite side of the bed from where I am working.
2. Making the bed in a hospital is just like making my bed at home.
3. A poorly made bed can contribute to the development of pressure ulcers.
4. Draw sheets are used to help lift and turn heavier patients.
Question 3
A student nurse is making up a bed while the patient is out receiving therapy. A supervising nurse intervenes when the student
1. Puts soiled linens on the floor.
2. Sprays a damp mattress with a disinfectant spray.
3. Removes the pillow from the pillowcase and places it in a chair.
4. Tucks the draw sheet between the mattress and springs.
Nursing care plan - risk for infection
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