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A nurse is preparing a client for transfer to another unit. Which of the following findings should the nurse include in the transfer report? (Select all that apply.)

Observations about family relationships

Response to pain medication

Review of ongoing discharge plan

Recent physical changes

Comprehensive demographic information

Answer and Explanation

Correct Answer : B,C,D

A. Observations about family relationships: Personal relationship details are not required unless relevant to care.

B. Response to pain medication: Pain management effectiveness is crucial for continuity of care.

C. Review of ongoing discharge plan: The receiving unit should be aware of discharge plans to provide appropriate care.

D. Recent physical changes: Any changes in condition must be reported for safe care continuation.

E. Comprehensive demographic information: Basic demographic details are in the medical record and do not need to be included in a verbal report.

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Correct Answer is A

Explanation

A. Nausea: Nausea is a sign of intolerance to enteral feedings and may indicate delayed gastric emptying or feeding that is too rapid. The nurse should slow the rate of feeding, assess for abdominal distention, and check for residual volume.

B. Urine output 40 mL/hr: Urine output of 40 mL/hr is within the normal range (≥30 mL/hr) and does not indicate intolerance to enteral feedings. However, a significant decrease in urine output (oliguria) could indicate dehydration or kidney issues.

C. Soft stools: Soft stools can be a normal response to enteral feedings unless the client develops diarrhea. Watery, frequent stools may indicate malabsorption, but soft stools alone are not a sign of feeding intolerance.

D. Headache: Headaches are not a common symptom of enteral feeding intolerance. They may be related to other issues such as dehydration, hypertension, or medication side effects.

A. Attach a probe carefully to the client's finger to prevent discomfort. B. Apply a sensor pad to the client's forehead. C. Secure a probe to one of the client's toes. D. Obtain a pulse oximetry reading when peripheral edema has decreased.

Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

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A nurse is preparing a client for transfer to another unit. Which of the following findings should the nurse include in the transfer report? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has been receiving intermittent enteral feedings which of the following findings should the nurse identify as an indication of intolerance to the feeding?

Correct Answer is A

Explanation

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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