A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
The frequency in which the client presses the call button
The client's most recent ventilator settings
The time of the client's last dose of pain medication
The last time the provider evaluated the client
The Correct Answer is C
A. The frequency in which the client presses the call button is not a priority for the change-of-shift report, as it does not indicate the level of pain or comfort of the client. This choice is incorrect.
B. The client's most recent ventilator settings are not applicable, as the client was weaned from mechanical ventilation and no longer requires it. This choice is incorrect.
C. The time of the client's last dose of pain medication is important for the change-of-shift report, as it helps to ensure continuity of care and prevent under- or over-medication of the client. This choice is correct.
D. The last time the provider evaluated the client is not relevant for the change-of-shift report, as it does not reflect the current status of the client. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.
Choice B reason
Shoulders is incorrect: The shoulders are not typically indicative of jaundice.
Choice C reason:
Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.
Choice D reason:
Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.
Correct Answer is A
Explanation
- Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
- AGNA have been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer. AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
- A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
- Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression. This may impair the healing process and increase the chances of complications after surgery or radiation therapy.
Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.
Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because increasing the client's dietary servings of fruits and vegetables may not have a significant impact on the levels of AGNA or Neu5Gc in the client's body.
Option C is incorrect because limiting the client's fluid intake to avoid hemodilution may not be necessary or beneficial for the client's condition.
Option D is incorrect because avoiding the client's exposure to cold temperatures may not be relevant or helpful for the client's condition.
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