The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?

Correct Answer: C

Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.

Correct Answer: C

Rationale: The correct answer is chocolate. Ingestion of chocolate can reduce lower esophageal sphincter (LES) pressure, leading to reflux and clinical symptoms of GERD. Lettuce, eggs, and butterscotch do not affect LES pressure and are less likely to trigger heartburn in individuals with GERD. Therefore, clients who are prone to developing heartburn due to GERD should avoid consuming chocolate to manage their symptoms effectively.

Correct Answer: C

Rationale: When transferring a client with hemiparesis from a bed to a wheelchair, it is crucial to ensure their safety. The correct safety measure is to move the wheelchair close to the client's bed and have the client stand and pivot on their unaffected extremity to the wheelchair. This method provides support with the unaffected limb, reducing the risk of falls or injuries. Choice A is incorrect as it suggests walking the client, which may not be safe or feasible. Choice C is incorrect because pivoting on the affected extremity can increase the risk of injury. Choice D is incorrect as it does not consider the client's limitations and safety needs, as it involves pushing their body which may not be possible with hemiparesis.

Correct Answer: D

Rationale: For a client with dumping syndrome, lying down 1 hour after eating helps reduce symptoms by slowing down the movement of food through the digestive tract, aiding in symptom management. This position assists in symptom management for dumping syndrome. Conversely, for a client with GERD, sitting up at least 30 minutes after eating can help prevent the backflow of stomach acid into the esophagus, reducing reflux symptoms. This upright position is beneficial for managing GERD. Choice A is incorrect because sitting up is recommended for GERD, not dumping syndrome. Choice C is incorrect as it suggests sitting up for both conditions, which is not appropriate. Choice D is incorrect as lying down after meals is not recommended for GERD; it can worsen symptoms by promoting acid reflux.

Correct Answer: B

Rationale: The correct answer is to use the defrost setting on microwave ovens to warm bottles. It is crucial to be cautious when heating bottles in a microwave to prevent milk from becoming superheated. The defrost setting is recommended, and the formula's temperature should always be checked before feeding the baby. Choice B, which advises to discard partially used bottles of refrigerated formula after 24 hours, is also correct. This is important to prevent the introduction of pathogens by the baby into the formula. Choice C, recommending mixing one part formula concentrate with two parts water, is essential for ensuring the correct dilution. Choice D, suggesting to discard any remaining portion of a bottle for the next feeding, is incorrect. It is not necessary to discard the remaining portion if it has been refrigerated promptly and used within a safe time frame. Adding fresh formula to a partially used bottle is not recommended, as it can lead to the growth of pathogens that may be transferred to the new formula.