A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.)
Primary health problem
Admission vital signs from 1 week ago
Scheduled times for dressing changes
Number of family members who have visited
Current medication prescriptions
Correct Answer : A,C,E
A. Primary health problem: This is correct as it provides critical context for the client's current condition and the reason for the transfer.
B. Admission vital signs from 1 week ago: This is incorrect because recent vital signs are more relevant to the current status of the client; historical data from a week ago is less pertinent.
C. Scheduled times for dressing changes: This is correct as it is important for the receiving unit to know about ongoing care needs related to wound management.
D. Number of family members who have visited: This is incorrect as it does not pertain to the client's medical condition or immediate care needs.
E. Current medication prescriptions: This is correct as it is essential for the new care team to have information on the medications the client is currently taking to ensure continuity of care.
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Related Questions
Correct Answer is A
Explanation
A. Participate in reminiscence therapy with the client: This is correct as reminiscence therapy, which involves discussing past experiences and memories, can help improve mood and cognitive function in clients with Alzheimer's disease.
B. Alternate the client's daily routine: Consistency is important for clients with Alzheimer's disease to reduce confusion and anxiety. Alternating the routine can be disorienting.
C. Keep the lights dimmed: Keeping the lights dimmed can contribute to confusion and disorientation. Adequate lighting is essential for safety and to help the client maintain a clear sense of time and space.
D. Raise the four side rails on the client's bed: Raising all four side rails can be considered a form of restraint and is not recommended. It can increase the risk of injury and does not address the client's needs appropriately.
Correct Answer is D
Explanation
A. "You may drink full liquids until 6 hours before the procedure": Typically, clients are instructed to follow a clear liquid diet and to stop drinking any liquids a few hours before the procedure, not full liquids.
B. "You will lie on your right side for the procedure": The client usually lies on their left side during a colonoscopy, not the right side.
C. "You should warm the liquid bowel preparation before drinking it": Bowel preparation solutions are generally not warmed; they are consumed as directed, often chilled to make them more palatable.
D. "You will be moderately sedated during the procedure": This is correct as colonoscopy usually involves moderate sedation to ensure client comfort and tolerance during the procedure.
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