The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to

ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the

client is supine in bed. The nurse telephoned the physical therapist about the difficulties

containing the drainage from the fistula, so the therapist didn't ambulate the client today. The

client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food

on her tray. The wound care nurse confirmed that she will see the client later today. The client

states she feels frustrated at not having physical therapy, but the nurse thinks the client

welcomed having a day to rest. Which of the following information should the nurse include in

the change-of-shift report? Select all that apply.

A. The physical therapist didn't ambulate the client today

B. The skin barrier's seal stays on in bed but loosens when the client stands.

C. The client seemed to welcome having a "day off" from physical therapy

D. The wound care nurse will see the client later today

E. The client ate all the food on her lunch tray

A, B, D

A nurse is receiving a provider's prescription by telephone for morphine for a client who is

reporting moderate to severe pain. Which of the following nursing actions are appropriate?

Select all that apply.

A. Repeat the details of the prescription back to the provider

B. Have another nurse listen to the telephone prescription

C. Obtain the prescriber's signature on the prescription within 24hrs

D. Decline the verbal prescription because it is not an emergency situation

E. Tell the charge nurse that the provider has prescribed morphine by telephone

A, B, C

A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He

states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To

which of the following members of the health care team should the nurse refer him?