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

Scheduled times for dressing changes

Number of family members who have visited

Current medication prescriptions

Answer and Explanation

Correct Answer : A,C,E

A. Primary health problem: This is correct as it provides critical context for the client's current condition and the reason for the transfer.
B. Admission vital signs from 1 week ago: This is incorrect because recent vital signs are more relevant to the current status of the client; historical data from a week ago is less pertinent.
C. Scheduled times for dressing changes: This is correct as it is important for the receiving unit to know about ongoing care needs related to wound management.
D. Number of family members who have visited: This is incorrect as it does not pertain to the client's medical condition or immediate care needs.
E. Current medication prescriptions: This is correct as it is essential for the new care team to have information on the medications the client is currently taking to ensure continuity of care.

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Correct Answer is A

Explanation

A. Dyspnea: This is correct as dyspnea (difficulty breathing) can be a sign of fluid overload, particularly when excess fluid accumulates in the lungs.
B. Pruritus: This is more indicative of an allergic reaction rather than fluid overload.
C. Fever: This is often associated with transfusion reactions or infection, not specifically fluid overload.
D. Bradycardia: This is less commonly associated with fluid overload and more often seen in other conditions or complications.

A. "I will increase vitamin C intake by drinking orange juice." B. "I will lie down for 30 minutes after each meal." C. "I will eat six small meals each day." D. "I will sleep flat on my back at night."

Correct Answer is C

Explanation

A. "I will increase vitamin C intake by drinking orange juice": This is incorrect because citrus juices like orange juice can exacerbate GERD symptoms by increasing acid production.
B. "I will lie down for 30 minutes after each meal": This is incorrect as lying down after eating can increase the risk of acid reflux. Clients should remain upright for at least 2-3 hours after eating.
C. "I will eat six small meals each day": This is correct because eating smaller, more frequent meals can help reduce the frequency of GERD symptoms by decreasing stomach pressure and acid production.
D. "I will sleep flat on my back at night": This is incorrect as sleeping flat can worsen GERD symptoms. Elevating the head of the bed can help prevent acid reflux during sleep.

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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

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Correct Answer is C

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