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.
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Related Questions
Correct Answer is D
Explanation
A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.
B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.
C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.
D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.
Correct Answer is D
Explanation
A. Wearing an N95 respirator is not necessary when caring for a client with neutropenia due to HIV unless the client has respiratory symptoms or is undergoing procedures that generate aerosols.
B. Inserting an indwelling urinary catheter should be avoided unless necessary, as it can
introduce the risk of infection, which is particularly concerning in clients with neutropenia.
C. Monitoring vital signs every 8 hours may not provide sufficient frequency for detecting changes in a client with neutropenia who may be at risk for rapid deterioration.
D. Using a dedicated stethoscope helps prevent the spread of infection to other clients by avoiding cross-contamination, which is especially important when caring for a client with neutropenia who is at increased risk of infection.
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