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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

All of the above

Rationale: The nurse should document all aspects of wound care, including the type and amount of dressing used, the location and size of the wound, and the appearance and odor of the wound. This information helps to monitor the healing process, evaluate the effectiveness of interventions, and identify any signs of infection or complications.

Incorrect options:

A) The type and amount of dressing used - This is an important information to document, but not the only one.

B) The location and size of the wound - This is an important information to document, but not the only one.

C) The appearance and odor of the wound - This is an important information to document, but not the only one.

A. An air leak in the system B. A normal functioning of the system C. A need to empty the collection chamber D. A need to clamp the chest tube

Correct Answer is A

Explanation

An air leak in the system

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system, which can compromise the negative pressure needed for effective drainage of air and fluid from the pleural space. The nurse should locate the source of the air leak and take appropriate measures to correct it. Possible sources of air leak include loose connections, cracks or holes in the tubing or drainage container, or a leak in the lung tissue.

Incorrect options:

B) A normal functioning of the system - Intermittent bubbling in the water seal chamber during inspiration, expiration, or coughing is a normal finding that indicates that air is being removed from the pleural space. Continuous bubbling is abnormal and indicates an air leak.

C) A need to empty the collection chamber - The collection chamber is where fluid drained from the pleural space accumulates. The nurse should empty the collection chamber when it is full or according to facility policy. Bubbling in the collection chamber is not a normal finding and does not indicate a need to empty it.

D) A need to clamp the chest tube - Clamping the chest tube is not recommended unless ordered by the provider or necessary for changing the drainage system. Clamping the chest tube can cause a buildup of pressure in the pleural space and lead to complications such as tension pneumothorax.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting the wound care provided to a client who has a pressure ulcer on the sacrum. Which information should the nurse include in the documentation?

Correct Answer is D

Explanation

A nurse is assessing a client who has a chest tube connected to a water seal drainage system. The nurse observes continuous bubbling in the water seal chamber. What does this finding indicate?

Correct Answer is A

Explanation

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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?