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. Glaucoma B. Asthma C. Migraine headaches D. Irritable bowel syndrome

Correct Answer is B

Explanation

A. Glaucoma: Propranolol is not contraindicated in clients with glaucoma. It may, however, need to be used cautiously if the client has narrow-angle glaucoma due to potential systemic effects.
B. Asthma: This is correct as propranolol, a non-selective beta-blocker, can exacerbate asthma by causing bronchoconstriction, making it contraindicated in individuals with asthma.
C. Migraine headaches: Propranolol is often used to prevent migraine headaches and is not contraindicated in this condition. It is actually considered an effective treatment for migraine prophylaxis.
D. Irritable bowel syndrome: Propranolol is not contraindicated in irritable bowel syndrome. There are no specific concerns regarding propranolol's use with this condition.

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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 monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who has hypertension and a new prescription for propranolol. Which of the following findings should the nurse identify as a contraindication for taking propranolol?

Correct Answer is B

Explanation

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