A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse?

A.

A. It's important to include the complete name of the medication to ensure clarity and accuracy in documentation.

B. Omitting the leading zero before a decimal point can lead to medication errors, so it's important to include it.

C. "U" is commonly used to denote units when documenting insulin dosage, so this statement is accurate.

D. "QOD" is an outdated abbreviation and can lead to confusion, so it should not be used; instead, "every other day" should be written out for clarity.

A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.

B. While vomiting after surgery may be noteworthy, the timing and amount of emesis

immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.

C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.

D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.