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 C
Explanation
A. A client with schizophrenia exhibiting apathy may require attention, but it may not be an immediate priority unless there are signs of deterioration or safety concerns.
B. A client with an anxiety disorder appearing restless may be experiencing distress, but it is not necessarily indicative of an immediate safety or crisis situation.
C. A client with major depressive disorder reporting hopelessness raises significant concern, as it may indicate an increased risk of self-harm or suicide. Clients expressing hopelessness should be assessed promptly to determine the level of risk and implement appropriate interventions.
D. A client with bipolar disorder exhibiting provocative behavior may pose a potential risk, but the level of urgency is typically higher for a client expressing hopelessness and depressive
Correct Answer is ["1.5"]
Explanation
To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
- Volume = 500 mg/ 330 mg/mL
- Volume≈1.5mL
Therefore, the nurse should administer approximately 1.5 mL per dose of cefazolin 500 mg IM.
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