A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

Admitting diagnosis

Breath sounds

Body temperature

Diagnostic test results

Answer and Explanation

The Correct Answer is B

When giving a change-of-shift report about a client with pneumonia, the priority piece of information for the nurse to provide is the client’s breath sounds. This is because breath sounds can indicate the severity of the pneumonia and the effectiveness of the treatment. Changes in breath sounds can signal a worsening condition that requires immediate medical attention.

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Correct Answer is C

Explanation

Choice A rationale

Inserting the needle at a 15-degree angle is not recommended for subcutaneous injections like heparin. The needle should be inserted at a 90-degree angle.

Choice B rationale

Aspirating for blood return before administration is not necessary when administering heparin.

Choice C rationale

Heparin should be administered into the abdominal fat layer, above the iliac crest and at least 2 inches away from the umbilicus.

Choice D rationale

Massaging the site after the injection is not recommended as it can cause bruising.

A. They allow the court to overrule an adult client’s refusal of medical treatment. B. They indicate the form of treatment a client is willing to accept in the event of a serious illness. C. They permit a client to withhold medical information from health care personnel. D. They allow health care personnel in the emergency department to stabilize a client’s condition.

Correct Answer is B

Explanation

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

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A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which piece of information is the priority for the nurse to provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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