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.)

Primary health problem

Admission vital signs from 1 week ago

Number of family members who have visited

Current medication prescriptions

Scheduled times for dressing changes

Answer and Explanation

Correct Answer : A,D,E

A. Primary health problem: Including the primary diagnosis or health problem ensures the receiving ICU team understands the client’s current medical condition and the reason for transfer. This information guides immediate interventions and prioritization of care.

B. Admission vital signs from 1 week ago: Historical vital signs from admission are generally not relevant for transfer documentation unless they reflect a trend affecting current status. The focus should be on recent and current assessments that impact immediate care.

C. Number of family members who have visited: While family presence is important for psychosocial support, it does not directly influence the ICU care plan. This information is not essential in transfer documentation for clinical management.

D. Current medication prescriptions: Accurate documentation of all current medications is critical to ensure continuity of care and prevent errors in the ICU. This includes dosages, routes, and timing to avoid omissions, duplications, or interactions.

E. Scheduled times for dressing changes: Providing information about ongoing treatments, such as wound care schedules, ensures the ICU team can continue necessary interventions without delay. This supports continuity and safety of care during the transfer.

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Correct Answer is C

Explanation

A. Poor judgment: Poor judgment is more commonly associated with right-hemisphere strokes due to impaired insight and spatial-perceptual deficits. It is less typical in clients with left-hemisphere strokes.

B. Left-sided weakness: Left-sided weakness results from right-hemisphere strokes because each hemisphere controls motor function on the opposite side of the body. A left-hemisphere stroke usually affects the right side.

C. Aphasia: The left hemisphere typically controls language, including speech and comprehension. A stroke in this area can result in expressive, receptive, or global aphasia, which is a hallmark finding in left-hemisphere strokes.

D. Impulsiveness: Impulsivity is more commonly seen in right-hemisphere strokes due to poor judgment, lack of awareness of deficits, and spatial-perceptual difficulties. It is not a primary characteristic of left-hemisphere strokes.

A. "I should limit my conversation with the client while wearing my mask." B. "After completing the suctioning. I should remove my gloves." C. "I will need to wear an N95 respiratory mask while suctioning the client." D. "I will pull the glove cuff over the wrist of the gown."

Correct Answer is C

Explanation

A. "I should limit my conversation with the client while wearing my mask.": Limiting unnecessary talking reduces the risk of mask contamination and prevents droplets from escaping around the mask. This reflects safe practice when working close to the airway during suctioning.

B. "After completing the suctioning, I should remove my gloves.": Gloves are removed first because they are the most contaminated item after suctioning. Taking them off immediately helps prevent cross-contamination and maintains correct PPE removal order. This shows appropriate understanding of PPE technique.

C. "I will need to wear an N95 respiratory mask while suctioning the client.": An N95 mask is not required for community-acquired pneumonia because it is transmitted by droplets, not airborne particles. A surgical mask provides adequate protection for droplet precautions. This statement shows misunderstanding and indicates a need for further teaching.

D. "I will pull the glove cuff over the wrist of the gown.": This technique prevents skin exposure and creates a proper seal between the glove and gown. It reduces the risk of contamination during suctioning procedures.

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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.)

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A nurse is caring for a client who recently experienced a left-hemisphere stroke. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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