A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

The client's most recent blood pressure reading was 110/60 mm Hg.

The client's morning laboratory results included a potassium level of 4.9 mg/dL.

The client has +2 pitting edema in the lower extremities.

The client's partner assisted them with their meal tray.

Answer and Explanation

The Correct Answer is D

The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.

A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.

The client's most recent blood pressure reading, morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.

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Correct Answer is B

Explanation

Explanation:

The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that aﬀects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.

Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.

A. Constipation B. Elevated skin patches C. Ringing in the ears D. Depression E. None F. None

Correct Answer is B

Explanation

Answer: B. Elevated skin patches

Rationale:

A. Constipation:
Constipation is not a typical adverse effect of cefazolin. Antibiotics generally cause gastrointestinal symptoms like diarrhea rather than constipation, so this is not a primary concern with cefazolin therapy.

B. Elevated skin patches:
Elevated skin patches may indicate an allergic reaction, such as hives or a rash, which can be a serious side effect of cefazolin. Allergic reactions to antibiotics can escalate quickly and may require immediate medical attention. Monitoring for and reporting any skin changes is important to prevent potential complications.

C. Ringing in the ears:
Tinnitus (ringing in the ears) is not commonly associated with cefazolin. This symptom is more frequently associated with certain other antibiotics, such as aminoglycosides, but is not a primary concern with cefazolin use.

D. Depression:
Depression is not a known side effect of cefazolin. While mood changes may be seen with some medications, cefazolin’s primary side effects are related to hypersensitivity reactions and gastrointestinal symptoms.

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A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?

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