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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Povidone-iodine may be used as a wound cleanser, but the method described here (using cotton balls) is not typically recommended as it can leave fibers in the wound.

B. Administering oral analgesia prior to wound irrigation may be appropriate for pain management but is not directly related to understanding wound irrigation technique.

C. Warming irrigation solution in a microwave oven can lead to uneven heating and potential tissue damage. This method is not recommended for warming irrigation solution.

D. Irrigating the wound from the top to the bottom ensures that contaminants are flushed away from the wound site, reducing the risk of infection and promoting healing. This indicates an understanding of proper wound irrigation technique.

A. A client who is 2 days postpartum and whose fundus is 2 fingerbreadths below the umbilicus B. A client who is 1 day postpartum and has not voided in 8 hr C. A client who is 3 days postpartum and has not had a bowel movement since prior to admission D. A client who is 4 days postpartum and has lochia serosa

Correct Answer is B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

Explanation

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