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

Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.

Choice B rationale

Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.

Choice C rationale

Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.

Choice D rationale

Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.

A. Place a pillow under the patient’s knees. B. Position a trochanter roll under each of the patient’s hips. C. Advise the patient to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the patient’s feet.

Correct Answer is D

Explanation

Choice A rationale

Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.

Choice B rationale

Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.

Choice C rationale

Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.

Choice D rationale

Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.

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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

A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given. Heart rate of 110 bpm Complete the following sentence using the list of options. The patient exhibits symptoms of ________

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a patient who has herpes zoster and is inquiring about the use of complementary and alternative therapies.Which of the following actions should the nurse take to reduce the patient’s risk of developing plantar flexion contractures?

Correct Answer is D

Explanation

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