A client who had a stroke is being transferred from the intensive care unit (ICU) to a rehabilitation unit. The ICU nurse is giving a handoff report to the rehabilitation nurse.
Which information should be included in the report?
The client's vital signs, laboratory results, and medications.
The client's medical history, diagnosis, and prognosis.
The client's functional status, goals, and discharge plan.
The client's preferences, family involvement, and psychosocial needs.
The Correct Answer is C
The client's functional status, goals, and discharge plan.
Rationale: The client's functional status, goals, and discharge plan are relevant information for the rehabilitation nurse, as they provide a baseline for assessing progress and planning interventions. The rehabilitation nurse will focus on helping the client regain function and independence, as well as preparing for discharge.
Incorrect options:
A) The client's vital signs, laboratory results, and medications. - This is not relevant information for the rehabilitation nurse, as these are routine data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will monitor these parameters as needed, but they are not essential for planning care.
B) The client's medical history, diagnosis, and prognosis. - This is not relevant information for the rehabilitation nurse, as these are general data that can be obtained from other sources, such as electronic records or charts. The rehabilitation nurse will be aware of these factors, but they are not specific for planning care.
D) The client's preferences, family involvement, and psychosocial needs. - This is not relevant information for the rehabilitation nurse, as these are subjective data that can be obtained from direct communication with the client and family. The rehabilitation nurse will address these aspects as part of holistic care, but they are not critical for planning care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To prevent lactic acidosis due to contrast dye
Rationale: Metformin is an oral antidiabetic agent that lowers blood glucose levels by decreasing hepatic glucose production and increasing peripheral glucose uptake. However, metformin can cause lactic acidosis, a rare but serious condition that occurs when lactate accumulates in the blood faster than it can be metabolized. Lactic acidosis can be triggered by contrast dye used for radiographic procedures, such as colonoscopy, especially in clients who have renal impairment or dehydration. Therefore, metformin should be discontinued 48 hours before and after any procedure that involves contrast dye.
Incorrect options:
A) To prevent hypoglycemia during fasting - This is not the rationale for discontinuing metformin, as metformin does not cause hypoglycemia by itself. However, the client may need to adjust the dose of other antidiabetic medications or insulin to prevent hypoglycemia during fasting.
C) To prevent hyperglycemia due to stress response - This is not the rationale for discontinuing metformin, as metformin does not cause hyperglycemia by itself. However, the client may need to monitor blood glucose levels more frequently and report any signs of hyperglycemia to the provider.
D) To prevent nephrotoxicity due to dehydration - This is not the rationale for discontinuing metformin, as metformin does not cause nephrotoxicity by itself. However, the client should be advised to maintain adequate hydration before and after the procedure to prevent dehydration and renal impairment.
Correct Answer is C
Explanation
"I will avoid foods that are high in calcium."
Rationale: Hydrochlorothiazide is a thiazide diuretic that lowers blood pressure by increasing urine output and reducing fluid volume. However, it also causes increased excretion of potassium and magnesium, and decreased excretion of calcium and uric acid. Therefore, clients taking hydrochlorothiazide should eat more foods that are rich in potassium and magnesium, such as bananas, oranges, potatoes, spinach, nuts, and seeds; limit their intake of sodium and fluids to prevent fluid retention and edema; avoid foods that are high in uric acid, such as organ meats, shellfish, and alcohol; and monitor their serum calcium levels regularly. There is no need to avoid foods that are high in calcium, as hydrochlorothiazide does not increase calcium excretion.
Incorrect options:
A) "I will eat more foods that are rich in potassium." - This is a correct statement, as hydrochlorothiazide causes increased potassium excretion and can lead to hypokalemia if not supplemented.
B) "I will limit my intake of sodium and fluids." - This is a correct statement, as sodium and fluids can cause fluid retention and edema, which can increase blood pressure and counteract the effects of hydrochlorothiazide.
D) "I will drink alcohol in moderation." - This is a correct statement, as alcohol can increase uric acid levels and cause gout attacks in clients taking hydrochlorothiazide. Alcohol can also lower blood pressure and increase the risk of orthostatic hypotension.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.