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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Correct Answer is A
Explanation
A. Fidelity refers to the concept of keeping promises or commitments made to clients. In this scenario, the nurse is demonstrating fidelity by informing the client that they will return as soon as possible with pain medication, indicating a commitment to addressing the client's needs promptly.
B. Justice pertains to fairness and equitable distribution of resources. It is not demonstrated in this scenario where the nurse is making a commitment to address the client's pain.
C. Autonomy involves respecting the client's right to make their own decisions and choices about their care. The nurse, in this case, is not specifically addressing the client's autonomy but rather demonstrating fidelity by committing to providing pain medication.
D. Nonmaleficence is the principle of doing no harm and ensuring the client's safety. While providing pain medication aligns with nonmaleficence by addressing the client's pain, the specific action of informing the client about the intent to return promptly falls more under the principle of fidelity.
Correct Answer is ["3"]
Explanation
To calculate the volume (mL) that the nurse should administer, we can follow these steps:
Convert the weight from pounds to kilograms.
- 1 lb = 0.453592 kg
- 165 lb×0.453592 kg/lb≈74.843 kg
Calculate the total dose using the weight and prescribed dose:
- Total Dose (units)=Dose per kg×Weight (kg)
- Total Dose=8 units/kg×74.843 kg≈598.744 units
Determine the volume using the concentration of the available solution:
- Volume (mL)=Total Dose (units)/Concentration (units/mL)
- Volume =598.744 units/200 units/mL ≈ 2.994 mL
Therefore, the nurse should administer approximately 3 mL of calcitonin for the 8 units/kg IM dose, rounded to the nearest whole number.
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