A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

"He appears anxious about the transfer."

"He is allergic to sulfa."

"His partner has been visiting."

"He is voiding adequately."

Answer and Explanation

The Correct Answer is B

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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Correct Answer is D

Explanation

Choice A Reason:

Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.

Choice B Reason:

Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.

Choice C Reason:

Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.

Choice D Reason:

Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.

A. Apply clean gloves. B. Ask the client to take a deep breath. C. Instill 50 mL of air into the tube. D. Pinch and withdraw the tube. E. Disconnect the tube from the suction device.

Correct Answer is E,C,B,D,A

Explanation

E. Disconnect the tube from the suction device:

Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.

C. Instill 50 mL of air into the tube:

Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.

B. Ask the client to take a deep breath:

Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.

D. Pinch and withdraw the tube:

Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.

A. Apply clean gloves:

Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.

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A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a laminectomy. Which of the following actions should the nurse take when repositioning the client?

Correct Answer is D

Explanation

A nurse is preparing to remove an NG tube for a client who is postoperative following colon surgery. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is E,C,B,D,A

Explanation

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