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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Related Questions
Correct Answer is ["10ml"]
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 = 500 mg/(250 mg/5 mL)
First, simplify the fraction:
Volume = 500mg/50 mg/mL
Now, determine the volume:
Volume =(500 mg/50 mg/mL)×(1 mL/1mg)
Volume=10mL
Therefore, the nurse should administer 10 mL of amoxicillin oral suspension for the 500 mg PO dose, rounded to the nearest whole number.
Correct Answer is ["500ml\/hr"]
Explanation
To calculate the mL/hr for the lactated Ringer's IV infusion over 30 minutes, you can use the following formula:
Rate (mL/hr)=Volume (mL)/Time (hr)
In this case:
Rate=250 mL/ 0.5 hr
Rate=500mL/hr
Therefore, the nurse should set the IV pump to deliver 500 mL/hr for the lactated Ringer's IV infusion over 1 hour.
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