A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

"The client in room 204 received some pain medicine earlier today."

"The client in room 205 has had several visitors."

"The client in room 205 is scheduled for a dressing change at 1800."

"The client in room 203 will undergo surgery at 0900 tomorrow."

"The client in room 204 has a new prescription for IV gentamicin."

Answer and Explanation

Correct Answer : C,D,E

A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.

B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.

C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.

E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.

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Correct Answer is C

Explanation

A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.

B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.

C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.

D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points

A. Neck is in a flexed position B. Asymmetry of gluteal folds C. Feet turn inward D. Frenulum connected to the tip of the tongue

Correct Answer is A

Explanation

A. Neck is in a flexed position is correct. Torticollis (or wry neck) is a condition where the head is tilted to one side due to abnormal positioning of the neck muscles. The infant may exhibit a flexed or tilted neck, and there may be muscle tightness on one side of the neck.

B. Asymmetry of gluteal folds is incorrect. This finding is associated with hip dysplasia, not torticollis. Asymmetry of the folds could indicate a dislocated hip or other musculoskeletal issues.

C. Feet turn inward is incorrect. This finding suggests clubfoot rather than torticollis, a condition where the feet are turned inward and may require correctional intervention.

D. Frenulum connected to the tip of the tongue is incorrect. This describes a condition known as tongue-tie (ankyloglossia., which affects the tongue's movement and is unrelated to torticollis.

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A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data from a 10-month-old infant during a well-child visit. Which of the following findings should the nurse identify as a manifestation of torticollis?

Correct Answer is A

Explanation

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