A nurse is assisting with the transfer of a patient from a medical-surgical unit to an intensive care unit following a change in status.
What information should the nurse include in the transfer documentation? (Select all that apply.)
Scheduled times for dressing changes.
Primary health problem.
Admission vital signs from 1 week ago.
Current medication prescriptions.
Number of family members who have visited.
Correct Answer : B,D
Choice A rationale
Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.
Choice B rationale
The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.
Choice C rationale
Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.
Choice D rationale
Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.
Choice E rationale
The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increasing vitamin C intake by drinking orange juice is not recommended for a patient with gastroesophageal reflux disease (GERD). Orange juice is acidic and can exacerbate the symptoms of GERD5.
Choice B rationale
Lying down for 30 minutes after each meal is not recommended for a patient with GERD. This can cause stomach acid to flow back into the esophagus, worsening GERD symptoms.
Choice C rationale
Eating six small meals each day is a good practice for a patient with GERD. Smaller meals are easier on the stomach and less likely to cause reflux.
Choice D rationale
Sleeping flat on the back at night is not recommended for a patient with GERD. Elevating the head of the bed can help prevent stomach acid from flowing back into the esophagus.
Correct Answer is D
Explanation
Choice A rationale
Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.
Choice B rationale
Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.
Choice C rationale
Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.
Choice D rationale
Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.
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