A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?
Daily bath given at 1000
Vomited a large amount of emesis immediately after surgery
Flushed IV with 0.9% sodium chloride
Pain relieved by position change
The Correct Answer is D
A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.
B. While vomiting after surgery may be noteworthy, the timing and amount of emesis
immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.
C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.
D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Brainstorming sessions are designed to generate new ideas and solutions by encouraging free thinking and creativity among participants. This approach can be effective in generating
innovative strategies to address public health concerns.
B. While a community-wide program may be part of addressing the issue, it does not inherently involve generating new ideas but rather implementing existing strategies on a larger scale.
C. Role-playing with nurses may be a training method to improve communication or intervention skills, but it is not specifically aimed at generating new ideas to address public health concerns.
D. Personal discussions with clients are important for providing individualized care and support but may not directly contribute to generating new ideas to address community-wide public health concerns.
Correct Answer is D
Explanation
- A. Clothing the newborn in light cotton is not recommended because it can block the light from reaching the skin, which is necessary for the treatment of hyperbilirubinemia through phototherapy.
- B. Checking the newborn's temperature every 8 hours is not frequent enough; during phototherapy, it is important to monitor the newborn's temperature more frequently to ensure they do not become too cold or too warm as a result of the therapy.
- C. Administering water between feedings is not recommended as it can interfere with the newborn's feeding schedule and nutrition; breast milk or formula provides adequate hydration unless otherwise indicated by a healthcare provider.
- D. Placing the newborn 45 cm (18 in) from the light source is the correct intervention. This distance allows for optimal exposure to the light while ensuring the safety and comfort of the newborn, as recommended in clinical guidelines for effective phototherapy.
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