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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is ["80"]

Explanation

To calculate the infusion rate in mL/hr for the gentamicin IV bolus, you can use the following formula:

Infusion Rate (mL/hr) = Volume (mL)/Time (hr)

In this case:

Infusion Rate=100 mL/1.25 hr

Infusion Rate=80mL/hr

Therefore, the nurse should ensure the IV pump is set to deliver 80 mL/hr for the gentamicin IV bolus, rounded to the nearest whole number.

A. Base appraisals on peer review from other AP. B. Examine the agency's job description for AP. C. Gather information from clients regarding the AP. D. Review the AP's previous performance appraisal.

Correct Answer is C

Explanation

A. Base appraisals on peer review from other AP:

While peer input can provide valuable insights, it's important to gather feedback from various sources, including those who directly interact with the AP, such as clients and nurses.

B. Examine the agency's job description for AP:

The job description provides information about the expectations and responsibilities of the AP. However, performance appraisal should involve more than just a comparison to the job description.

C. Gather information from clients regarding the AP:

This is the correct answer. Clients can provide valuable feedback on the care and services they receive from the AP. Their perspective can contribute to a more comprehensive assessment of the AP's performance.

D. Review the AP's previous performance appraisal:

While reviewing previous appraisals can offer historical context, it's essential to gather current information to assess the AP's current performance and growth.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["80"]

Explanation

A nurse is asked by the unit manager to provide input for the performance appraisal of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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