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 ["A","B","C","D"]

Explanation

A. Blood pressure: The client’s blood pressure (92/60 mm Hg) is low, which is concerning, especially with tachycardia (HR 106). This may indicate hypovolemia or shock, which requires immediate attention.
B. BUN level: The BUN level (25 mg/dL) is elevated above the normal range, which could indicate dehydration or kidney dysfunction, often seen in conditions like gastrointestinal obstruction or sepsis.
C. Potassium level: The potassium level (3.3 mEq/L) is below the normal range (3.5 to 5 mEq/L), which can contribute to arrhythmias and muscle weakness, often a result of vomiting, diarrhea, or dehydration.
D. Abdominal findings: The high-pitched bowel sounds and tenderness are consistent with an intestinal obstruction, and further assessment and intervention are necessary to manage the condition effectively.
E. WBC count: The WBC count (9,000/mm³) is within the normal range, suggesting no active infection or inflammation at the moment.
F. Breath sounds: Bilateral breath sounds are clear, which suggests no current respiratory issues or pneumonia, allowing the focus to remain on gastrointestinal findings.

A. Restrict visitors to family members until the client is able to wear a prosthesis. B. Encourage the client to talk with another client who completed rehabilitation for amputation. C. Instruct the client to ignore phantom pain sensations. D. Suggest that family members bring clothing for the client from home. E. Ask the client to describe her feelings about the loss of the affected limb.

Correct Answer is ["B","D","E"]

Explanation

A. Restrict visitors to family members until the client is able to wear a prosthesis: Restricting visitors may increase isolation and hinder emotional support.
B. Encourage the client to talk with another client who completed rehabilitation for amputation: Peer support can provide emotional reassurance and motivate the client in their recovery process.
C. Instruct the client to ignore phantom pain sensations: Phantom pain is real and should not be dismissed; it requires management through medication or other interventions.
D. Suggest that family members bring clothing for the client from home: Familiar clothing can improve self-esteem and promote adjustment to body image changes.
E. Ask the client to describe her feelings about the loss of the affected limb: Exploring the client’s feelings helps address emotional and psychological aspects of coping with amputation.

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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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Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a client. Exhibits The nurse is collecting data on the client. Which of the following findings require follow-up? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse at a rehabilitation facility is contributing to the plan of care for a client who has had a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

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