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 not include in the change-of-shift report?
The last time the provider evaluated the client
The client's most recent ventilator settings
The time of the client's last dose of pain medication
The frequency in which the client presses the call button
None
None
The Correct Answer is D
A. The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.
B. The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.
C. The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.
D. The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.
B: Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.
C: Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.
D: Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.
Correct Answer is ["B","C","E","F"]
Explanation
The four findings that require follow-up are B, C, E, and F.
Rationale:
- Blood pressure: A normal blood pressure for an adolescent is 110/70 mm Hg. The question does not provide the adolescent's blood pressure, so it cannot be determined if it requires followup or not.
- Capillary refill: A normal capillary refill time is less than 2 seconds. A prolonged capillary refill time indicates impaired blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pedal pulse: A normal pedal pulse is +2 or +3. A weak pedal pulse (+1) indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Heart rate: A normal heart rate for an adolescent is 60 to 100 beats per minute. The question does not provide the adolescent's heart rate, so it cannot be determined if it requires follow-up or not.
- Skin temperature: A normal skin temperature is warm and dry. A cool skin temperature indicates reduced blood flow to the extremity, which could be due to vascular injury, compartment syndrome, or shock.
- Pain: A pain level of 10 on a scale of 0 to 10 indicates severe pain that needs to be managed with appropriate analgesics and nonpharmacological interventions.
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