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. "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.
Correct Answer is C
Explanation
A. Elevate the head of the bed 45° before starting the CPM device: This is not necessarily required and may not be appropriate based on the specific needs of the client or the setup of the CPM device.
B. Ensure the frame joint is in a flexed position before placing the leg onto the device: This is incorrect as the CPM device should be properly aligned with the joint's neutral position to avoid discomfort and ensure effective movement.
C. Ensure the knee joint is positioned over the CPM device frame joint: This is correct as proper alignment ensures that the device functions effectively and helps in the controlled movement of the knee joint.
D. Instruct the client to increase the degree of flexion as tolerated: This is incorrect as the degree of flexion should be adjusted according to the provider’s orders, not based on the client’s tolerance alone.
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