A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

"The client in room 204 received some pain medicine earlier today."

"The client in room 205 has had several visitors."

"The client in room 205 is scheduled for a dressing change at 1800."

"The client in room 203 will undergo surgery at 0900 tomorrow."

"The client in room 204 has a new prescription for IV gentamicin."

Answer and Explanation

Correct Answer : C,D,E

A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.

B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.

C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.

E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.

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Correct Answer is C

Explanation

A. Replace the NG tube.: There is no indication that the NG tube is malfunctioning or misplaced in this case. The cramping and nausea are more likely related to the feeding itself, not the tube.

B. Lower the head of the bed to 15°.: Lowering the head of the bed would increase the risk of aspiration. The head of the bed should be elevated during enteral feeding to reduce this risk.

C. Slow the rate of formula instillation.: Abdominal cramping and nausea during enteral feeding can occur if the feeding rate is too fast. Slowing the rate allows the stomach to better tolerate the formula and can alleviate symptoms.

D. Chill and readminister the formula.: The temperature of the formula should not cause the cramping or nausea. Feeding should be administered at room temperature or as directed by protocol, and re-chilling it is unlikely to help with the symptoms.

A. "I can have a meal up to 2 hours before the procedure." B. "I will feel a warming sensation after the injection of the dye contrast." C. "I do not need to sign a consent form before this procedure." D. "I should limit my fluid intake for 2 days after the procedure."

Correct Answer is B

Explanation

A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.

B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.

C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.

D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.

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A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an intermittent enteral feeding through a client's NG tube. During the instillation, the client reports abdominal cramping and nausea. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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