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A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
- A. Plan of care changes for the upcoming shift
- B. Intracranial pressure readings
- C. Glasgow results
- D. Code status
Correct Answer: D
Rationale: The correct answer is D: Code status. In the background segment of SBAR, the nurse should include the client's code status to ensure the oncoming nurse is aware of the client's wishes in case of a medical emergency. This information is crucial for providing appropriate care and making decisions aligned with the client's preferences. Intracranial pressure readings (B) and Glasgow results (C) are more specific to the current condition of the client and would be included in the assessment segment of SBAR. Plan of care changes for the upcoming shift (A) would be part of the recommendation segment.
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A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first?
- A. Verify the provider’s prescription to discontinue the tube.
- B. Disconnect the tube from the wall suction.
- C. Perform hand hygiene.
- D. Provide mouth care to the client.
Correct Answer: A
Rationale: The correct answer is A: Verify the provider’s prescription to discontinue the tube. This is the first step because removing an NG tube without a prescription could lead to serious complications. The nurse must ensure that it is safe and appropriate to remove the tube as per the provider's orders. Disconnecting the tube from the wall suction (B) should only be done after verifying the prescription. Performing hand hygiene (C) and providing mouth care to the client (D) are important steps in the process but should come after confirming the prescription.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
- A. Take the medication with orange juice.
- B. Take the medication between meals.
- C. Take the medication on an empty stomach.
- D. Take the medication with milk.
Correct Answer: D
Rationale: The correct answer is D: Take the medication with milk. Betamethasone can cause stomach irritation, so taking it with milk can help reduce this side effect. Milk coats the stomach lining, providing a protective barrier. This helps to minimize the risk of gastrointestinal upset.
A: Taking the medication with orange juice is not recommended as it can increase stomach irritation due to its acidity.
B: Taking the medication between meals may not provide the same protective effect on the stomach lining as taking it with milk.
C: Taking the medication on an empty stomach can increase the risk of gastrointestinal irritation and should be avoided.
E, F, G: These options are not relevant to the administration of betamethasone.
A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
- A. Constipation
- B. Sensitivity to cold
- C. Weight gain of 4.5 kg (10 lbs) in 3 weeks
- D. Frequent mood changes
Correct Answer: D
Rationale: The correct answer is D: Frequent mood changes. In hyperthyroidism, there is an excessive production of thyroid hormones leading to symptoms such as irritability, anxiety, and mood swings. This is due to the increased metabolic activity caused by the excess thyroid hormones. Constipation (A) is more common in hypothyroidism. Sensitivity to cold (B) is also seen in hypothyroidism due to decreased metabolic rate. Weight gain of 4.5 kg (10 lbs) in 3 weeks (C) is unlikely in hyperthyroidism as it usually leads to weight loss. Therefore, choice D is the most appropriate manifestation for hyperthyroidism.
A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility?
- A. Health care provider
- B. Hospital pharmacist
- C. Nurse manager
- D. Medication sales representative
Correct Answer: B
Rationale: The correct answer is B: Hospital pharmacist. The nurse should consult the pharmacist first for medication compatibility as they are experts in drug interactions and compatibility. Pharmacists can provide specific guidance on whether ampicillin and gentamicin sulfate can be safely administered together via IV infusion. Consulting the health care provider (choice A) may also be necessary for prescribing information, but pharmacists have specialized knowledge on drug interactions. The nurse manager (choice C) may not have the expertise in medication compatibility. Consulting a medication sales representative (choice D) is not appropriate as their role is to promote and sell medications rather than provide clinical guidance on compatibility.