A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)

Current medication prescriptions

Primary health problem

Number of family members who have visited

Admission vital signs from 1 week ago

Scheduled times for dressing changes

Answer and Explanation

Correct Answer : A,B,E

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

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Correct Answer is B

Explanation

A. "Encourage socialization as a distractor when the client becomes agitated.": Socialization might exacerbate agitation; calm environments and redirection are better strategies.
B. "Limit instructions to two steps at a time.": Simplified instructions accommodate the cognitive limitations of Alzheimer’s clients, reducing confusion and frustration.
C. "Vary the staff providing care for the client.": Consistent caregivers are essential for maintaining familiarity and reducing anxiety in clients with Alzheimer's disease.
D. "Encourage independence in ADLs.": Independence should only be encouraged as much as the client can manage safely; overemphasis might lead to frustration or harm.

A. Perform suctioning. B. Instill saline into the tubing. C. Increase the humidification. D. Check the cuff pressure.

Correct Answer is A

Explanation

A. Perform suctioning: Restlessness and crackles in the lungs may indicate retained secretions. Suctioning the tracheostomy can help clear secretions and improve oxygenation.
B. Instill saline into the tubing: Routine instillation of saline is not recommended as it can cause discomfort, dislodge bacteria, or create a risk of aspiration.
C. Increase the humidification: While humidification helps prevent mucus from becoming thick, it does not address the immediate issue of retained secretions causing crackles.
D. Check the cuff pressure: While it is important to ensure appropriate cuff pressure, this is not the primary intervention for resolving restlessness and crackles, which suggest secretion buildup.

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A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has a tracheostomy tube. Upon data collection, the nurse observes the client is restless and hears crackles in the lungs. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

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A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)