A nurse is assisting with the transfer of a patient from a medical-surgical unit to an intensive care unit following a change in status.
What information should the nurse include in the transfer documentation? (Select all that apply.)

Scheduled times for dressing changes.

Primary health problem.

Admission vital signs from 1 week ago.

Current medication prescriptions.

Number of family members who have visited.

Answer and Explanation

Correct Answer : B,D

Choice A rationale

Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.

Choice B rationale

The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.

Choice C rationale

Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.

Choice D rationale

Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.

Choice E rationale

The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Discontinuing the nasogastric tube is not the best action to take at this time. The nasogastric tube may be necessary for decompression of the stomach or administration of medications and should not be removed without a specific order from the healthcare provider.

Choice B rationale

Providing the client with ice chips is not the most appropriate action. The client is kept NPO (nothing by mouth) before surgery to prevent aspiration during anesthesia. Therefore, giving the client ice chips could increase the risk of aspiration.

Choice C rationale

Starting the prescribed antibiotic is the correct action. Cefazolin is an antibiotic that is often given before surgery to prevent postoperative infections. Administering this medication as ordered can help to ensure that the client is adequately prepared for surgery.

Choice D rationale

While reinforcing preoperative teaching is an important part of nursing care, it is not the most immediate action that should be taken in this situation. The client’s physical preparation for surgery, including the administration of prescribed medications, should be prioritized.

A. Compare the reading to the preoperative value. B. Cover the patient with a warm blanket. C. Increase the IV flow rate. D. Reassure the patient.

Correct Answer is A

Explanation

Comparing the current blood pressure reading to the preoperative value is the first step the nurse should take. This will help determine if the patient’s blood pressure has significantly dropped, which could indicate hypovolemia or shock.

Choice B rationale

Covering the patient with a warm blanket may be helpful if the patient is feeling cold or showing signs of hypothermia, but it would not address the underlying cause of the low blood pressure.

Choice C rationale

Increasing the IV flow rate might be necessary if the patient is hypovolemic, but this decision should be based on additional assessment data and physician orders.

Choice D rationale

Reassuring the patient is important, but it should not be the first action. The nurse needs to assess and address the cause of the low blood pressure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the transfer of a patient from a medical-surgical unit to an intensive care unit following a change in status.What information should the nurse include in the transfer documentation? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On Day 2 at 16:00, the client is kept NPO.An exploratory laparotomy is scheduled for tomorrow at 06:00. Metoclopramide 10 mg IV every 6 hours and Cefazolin 2g IV on call for surgery are ordered.Which of the following actions should the nurse assist with?

Correct Answer is C

Explanation

A nurse is assessing a patient who is 8 hours postoperative following abdominal surgery. The patient’s blood pressure is 94/56 mm Hg. What should the nurse do first?

Correct Answer is A

Explanation

A nurse is providing care for a patient who is in skeletal traction. Which action should the nurse take?

A nurse is reviewing the medical record of a patient who has hypertension and a new prescription for propranolol. What findings should the nurse identify as a contraindication for taking propranolol?

A nurse is providing discharge instructions to a patient about self-administration of regular insulin. Which of the following instructions should be included by the nurse?

A nurse in a provider’s office is talking with a patient who takes oxybutynin. The patient asks why he does not urinate as often.Which of the following information should the nurse include about the action of oxybutynin?

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hours to an older adult patient who has rhinitis.The available medication is diphenhydramine syrup 12.5 mg/5 mL. How many mL should the nurse administer?

A nurse is preparing a patient for a sigmoidoscopy. In which of the following positions should the nurse place the patient?

A nurse is caring for a patient who is one day postoperative following an appendectomy. What findings should the nurse report?

A nurse is assisting with the transfer of a patient from a medical-surgical unit to an intensive care unit following a change in status.
What information should the nurse include in the transfer documentation? (Select all that apply.)