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 B
Explanation
A. Speech therapist: A speech therapist is typically involved in addressing communication and swallowing difficulties, not difficulties with using utensils.
B. Occupational therapist: This is correct as an occupational therapist specializes in helping clients with daily living activities, including fine motor skills and adaptive techniques for using utensils.
C. Physical therapist: Physical therapists focus on improving mobility, strength, and coordination but do not primarily address difficulties with using utensils.
D. Recreational therapist: Recreational therapists focus on leisure activities and hobbies, which are not directly related to the use of utensils for eating.
Correct Answer is B
Explanation
A. Apply a heat pack to the client's lower abdomen: This is incorrect as applying heat can worsen inflammation and increase the risk of rupture; ice packs are generally used instead.
B. Place the client in semi-Fowler's position: This is correct as the semi-Fowler's position helps reduce pain and pressure on the abdomen and can improve comfort before surgery.
C. Give the client a clear liquid diet: This is incorrect as a clear liquid diet is not appropriate for a client with acute appendicitis who may require NPO (nothing by mouth) status prior to surgery.
D. Administer an enema to the client: This is incorrect as enemas are contraindicated in acute appendicitis due to the risk of perforation and worsening of the condition.
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