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 D

Explanation

A. Offer snacks that are high in sodium: This is incorrect as high sodium intake can exacerbate heart failure by increasing fluid retention and worsening symptoms.
B. Place the head of the client's bed flat: This is incorrect because elevating the head of the bed helps reduce shortness of breath and improves comfort in heart failure patients.
C. Monitor the client's weight once per week: This is incorrect; daily weight monitoring is recommended to detect fluid retention or loss, which can be critical in managing heart failure.
D. Provide rest periods throughout the day: This is correct as providing rest periods helps manage fatigue and reduce the workload on the heart, which is important in heart failure management.

A. Temperature B. Heart rate C. Skin findings D. Respiratory rate E. Oxygen saturation F. Blood pressure G. Urinary output

Correct Answer is ["B","F","G"]

Explanation

A. Temperature: The temperature remains stable and within normal limits. A postoperative temperature range of 36.3° C (97.3° F) to 36.4° C (97.5° F) is not indicative of infection or other complications at this time.

B. Heart rate: The heart rate has increased from 84/min to 104/min, indicating sinus tachycardia. This could be a compensatory response to decreased blood volume or another underlying issue, necessitating further assessment.

C. Skin findings: The skin findings are described as warm and dry, which is normal. No abnormalities are noted, so this does not require follow-up.

D. Respiratory rate: The respiratory rate has increased slightly to 24/min but is not significantly abnormal. This may not be a priority for follow-up unless other symptoms are present.

E. Oxygen saturation: The oxygen saturation is within normal limits (96% on room air), suggesting adequate oxygenation. No immediate concerns are evident based on this measurement.

F. Blood pressure: The blood pressure has dropped from 106/74 mm Hg to 88/54 mm Hg, indicating possible hypotension. This drop could signal hypovolemia or bleeding, requiring prompt follow-up to investigate the cause.

G. Urinary output: The urinary output of 110 mL over 6 hours is low, which might indicate dehydration or renal issues. Monitoring and addressing this finding are important to ensure adequate fluid balance and kidney function.

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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 assisting with the plan of care for a client who has heart failure. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

A nurse on a medical-surgical unit is assisting in the care of a male client. Exhibits Which of the following findings indicate a need for follow-up by the nurse? Select all that apply.

Correct Answer is ["B","F","G"]

Explanation

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