A nurse working in a long-term care facility is giving change-of-shift report on a client who had a stroke. Which of the following information should the nurse include in the report?
The client's blood pressure was recorded at 0730 and 1130.
The client's pain medication was administered twice during this shift.
The client's enteral feeding bag needs to be changed at 2200.
The client received a bath and backrub.
The Correct Answer is A
A. The client's blood pressure was recorded at 0730 and 1130.
In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.
B. The client's pain medication was administered twice during this shift:
While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.
C. The client's enteral feeding bag needs to be changed at 2200:
While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.
D. The client received a bath and backrub:
Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12"]
Explanation
To calculate the volume (mL) that the nurse should administer, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
Volume = 300 mg/ (125mg/5 mL)
First, simplify the fraction:
Volume = 300 mg/25 mg/mL
Now, determine the volume:
Volume =(300 mg/25mg/mL) × (1mL/1mg)
Volume=12mL
Therefore, the nurse should administer 12 mL of phenytoin oral suspension for the 300 mg PO dose, rounded to the nearest whole number.
Correct Answer is D
Explanation
A. The statement "Libel is the intentional infliction of emotional distress due to negligent nursing actions" is incorrect. Libel refers to written or published false statements that damage a person's reputation. It is not related to intentional infliction of emotional distress or negligence in nursing actions. This statement reflects a misunderstanding of the concept of libel.
B. The statement "Documenting negative opinions about a client's personality is considered libel" is also incorrect. Libel involves false statements, and expressing negative opinions, even in documentation, may not necessarily qualify as false unless they are untrue statements. However, negative opinions about a client's personality may be considered unprofessional or inappropriate, but they do not constitute libel.
C. The statement "Failing to complete an incident report following a client injury is an act of libel" is incorrect. Libel is related to false statements, and failing to complete an incident report is a failure in documentation but does not inherently involve making false statements. This statement demonstrates a misunderstanding of what constitutes libel.
D. The statement "A nurse can be charged with libel if she discusses client information in a public area" is correct. Discussing client information in a public area, where unauthorized individuals may overhear and obtain sensitive information, can be a violation of confidentiality. While it may not strictly be libel, it could lead to legal and ethical consequences. This statement reflects an understanding of the importance of maintaining client confidentiality and the potential legal implications of disclosing private information in public areas.
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