The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included?

• As-needed medications given that shift
• Normal vital signs that have been normal since admission
• All of the tests and treatments the client has had since admission
• Total number of scheduled medications that the client received on that shift

Answer explanation

The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift.

It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns.

It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

• Hold the feeding.
• Document the amount of residual.
• Place it into a container for laboratory analysis.
• Reinstill the residual and administer the feeding.
• Deduct the amount of the residual from the new feeding before administering.

Answer explanation

Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled; then a normal amount of prescribed tube feeding is administered.

The amount of residual should be documented. It is important to return the contents to the stomach to prevent electrolyte imbalances.

The feeding is not held, and the residual is not sent to the laboratory. The tube feeding should continue at the prescribed rate.

The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently?

• Every hour
• Every 2 hours
• Every 3 hours
• Every 4 hours

Answer explanation

Safe nursing practice includes monitoring an IV infusion at least once every 1 hour for an adult client.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position?

• Prone
• Reverse Trendelenburg's
• Supine, with the residual limb flat on the bed
• Supine, with the residual limb supported with pillows

Answer explanation

The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema.

After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques.

In addition, it is important to check the surgeon's prescription(s) regarding positioning following amputation.

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?

• Taking a rectal temperature for a client who has undergone nasal surgery
• Taking an oral temperature for a client with a cough and nasal congestion
• Taking an axillary temperature on a client who has just consumed hot coffee
• Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

Answer explanation

An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available.

Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable.

Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available.

If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.