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 D
Explanation
A. Elevate legs on pillows when in bed: This is incorrect because elevating the legs can reduce blood flow in peripheral arterial disease, and it is generally advised to keep the legs at the level of the heart or lower to promote better circulation.
B. Apply heating pad for 15 min twice per day: This is incorrect because applying heat directly to the legs is not recommended as it can lead to burns or other complications, especially in patients with peripheral vascular issues.
C. Wear knee-high support hose during the day: This is incorrect because support hose can sometimes exacerbate symptoms of peripheral arterial disease by restricting blood flow. Compression stockings are generally not recommended.
D. Begin an exercise program that includes walking: This is correct because walking and other forms of exercise improve circulation and help alleviate symptoms of peripheral arterial disease by promoting better blood flow and cardiovascular health.
Correct Answer is B
Explanation
A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.
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