A nurse is providing a change-of shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?
Client was nauseated immediately after surgery.
Client's pain relieved by position change.
Checked for peripheral IV blood return prior to antibiotic.
Client provided with breakfast tray at 0800.
The Correct Answer is B
A. Client was nauseated immediately after surgery: While postoperative nausea is important to document, it is an event that occurred in the past and may not reflect the client’s current status 36 hours after surgery.
B. Client’s pain relieved by position change: This information is critical as it reflects the current effectiveness of nonpharmacologic pain management strategies and guides ongoing care for comfort.
C. Checked for peripheral IV blood return prior to antibiotic: This is a routine nursing task that was completed. While important for safe medication administration, it's a procedural detail of a completed task and not usually included in a concise shift report.
D. Client provided with breakfast tray at 0800: Although documenting nutrition is important, the exact timing of meal delivery is less significant than clinical status information during shift handoff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Season foods with salt and pepper.": Spicy and seasoned foods can irritate the gastric mucosa, potentially worsening gastritis symptoms, so this advice is not appropriate.
B. "Eat small frequent meals daily.": Smaller, more frequent meals help reduce gastric acid secretion and minimize irritation of the stomach lining, which can alleviate symptoms of gastritis and promote healing.
C. "Use ibuprofen as needed for discomfort.": Nonsteroidal anti-inflammatory drugs like ibuprofen can exacerbate gastritis by irritating the stomach lining and increasing the risk of bleeding, so they should be avoided.
D. "Take a Vitamin E supplement daily.": There is no clear evidence supporting the use of vitamin E supplements for gastritis management, and supplementation is not a standard recommendation in this condition.
Correct Answer is A
Explanation
A. Measure the tubing from the nose to the distal port: Proper measurement of the NG tube ensures correct placement into the stomach. The usual method involves measuring from the tip of the nose to the earlobe and then to the xiphoid process, not to the distal port of the tube, but this choice most closely aligns with verifying safe tube length.
B. Complete the feeding in 5 min: Administering a feeding too quickly can cause abdominal cramping, vomiting, or aspiration. Feedings should be given slowly, typically over 15 to 30 minutes, depending on the child's tolerance and the volume.
C. Warm the formula in the microwave: Microwaving formula can cause uneven heating and result in hot spots that may burn the child’s mouth or GI tract. Formula should be warmed by placing the container in warm water and testing the temperature before administration.
D. Position the child at a 10° to 20° angle after feeding: This angle is too low and increases the risk of aspiration. The child should remain at a 30° to 45° angle for at least 30 minutes after feeding to promote digestion and prevent reflux.
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