A nurse is transferring a patient who suffered a spinal cord injury at C4, has a tracheostomy, and receives tube feedings through a jejunostomy tube to a long-term care facility. What information should the nurse include in the handoff?
Select all that apply.
A. The last time the patient had a bowel movement
B. The patient's motor and sensory responses
C. The last dose of medication received
D. The patient's food preferences
Question 2
A client who was involved in a motor vehicle accident is admitted through the emergency department. He has an IV of 0.9 NS 100 mL/hr, BP 92/58, and complains of weakness, fatigue, and abdominal pain.
On assessment, the nurse discovers that Mr. Reynolds is nauseated and just vomited 560 milliliters of green emesis with flecks of coffee grounds. The nurse delegates client care activities to the nursing assistive personnel. Which activity should the nurse keep?
A. Taking and recording vital signs every 15 minutes
B. Recording accurate intake and output
C. Obtaining a baseline weight to guide therapy
D. Increasing the IV rate to 250 mL/hr if the blood pressure drops to 85/50
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