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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Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

Correct Answer is ["4"]

Explanation

To calculate the volume (mL) that the nurse should administer per dose, you can use the following formula:

Volume (mL) = Dose (units)/Concentration (units/mL)

In this case:

Volume = 400,000 units/100,000 units/mL
Volume=4mL

Therefore, the nurse should administer 4 mL of Mycostatin oral suspension per dose.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

Correct Answer is B

Explanation

A nurse is preparing to administer mycostatin 400,000 units PO every 6 hr. Available is mycostatin oral suspension 100,000 units/mL. How many ml should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

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