a nurse is preparing a client for transfer to another unit which finding should the nurse include in the transfer report a nurse is preparing a client for transfer to another unit which finding should the nurse include in the transfer report
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Nursing Elites

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1. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?

Correct answer: B

Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.

2. During the nurse’s initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?

Correct answer: B

Rationale: Pain management should be based on the child’s report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child’s parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.

3. A nurse is preparing to administer a gavage feeding via a nasogastric tube to a preterm newborn who is receiving supplemental oxygen. Which of the following actions should the nurse take?

Correct answer: C

Rationale: Measuring the stomach aspirate prior to the feeding is crucial to ensure the correct placement and function of the nasogastric tube. This step helps prevent complications such as aspiration or improper feeding. Choice A is incorrect as stabilizing the tube with tape to the newborn’s cheek can cause discomfort and skin irritation. Choice B is incorrect because removing supplemental oxygen during the feeding may compromise the newborn's respiratory status. Choice D is incorrect because placing the newborn on their left side for 30 minutes after the feeding is not a standard practice and is unnecessary for administering gavage feeding.

4. A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?

Correct answer: B

Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.

5. What is the typical presentation of pyloric stenosis in infants?

Correct answer: B

Rationale: The correct answer is B: Projectile vomiting. Pyloric stenosis in infants typically presents with projectile vomiting, which is forceful and projective in nature. This occurs due to the obstruction at the pylorus, leading to the stomach being unable to empty properly. Choices A, C, and D are incorrect. Bilious vomiting is more commonly associated with intestinal obstruction, blood in stools can occur in conditions such as necrotizing enterocolitis or allergic colitis, and failure to thrive is a nonspecific finding that can be seen in various pediatric conditions.

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