A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

"The client in room 204 received some pain medicine earlier today."

"The client in room 205 has had several visitors."

"The client in room 205 is scheduled for a dressing change at 1800."

"The client in room 203 will undergo surgery at 0900 tomorrow."

"The client in room 204 has a new prescription for IV gentamicin."

Answer and Explanation

Correct Answer : C,D,E

A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.

B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.

C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.

E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.

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Correct Answer is A

Explanation

A. "You should not palpate your child's abdomen prior to surgery." is correct. Palpating the abdomen of a child with Wilms' tumor should be avoided, as this could cause the tumor to rupture and spread cancerous cells. The tumor is typically confined to one kidney and must be surgically removed.

B. "Your child should have surgery in 7 to 10 days to remove the tumor." is incorrect. Surgery to remove a Wilms' tumor typically occurs within 24 to 48 hours after diagnosis, not within 7 to 10 days.

C. "You should give your child captopril 200 mg PO daily." is incorrect. Captopril is not a standard medication used in the treatment of Wilms' tumor. Treatment often involves surgery, chemotherapy, and sometimes radiation therapy.

D. "Your child will not require further treatment after removal of the tumor." is incorrect. Post-surgical treatment, such as chemotherapy and/or radiation therapy, is often required, depending on the stage and extent of the tumor.

A. Check the client's vital signs every 4 hr. B. Provide the client with high-calorie finger foods. C. Encourage the client to participate in group activities. D. Allow the client to establish his own schedule.

Correct Answer is B

Explanation

A. Check the client's vital signs every 4 hr.: Although monitoring vital signs is important, it is not the primary concern in acute mania unless the client is showing signs of physical distress (e.g., tachycardia, dehydration).

B. Provide the client with high-calorie finger foods.: This is correct. During acute mania, clients may have difficulty sitting down to eat, and high-calorie finger foods can help ensure the client gets adequate nutrition. These foods are easy to consume and provide the necessary calories.

C. Encourage the client to participate in group activities.: While socialization can be beneficial, group activities may overstimulate a client in acute mania and could lead to further agitation. It is better to encourage more structured and individual activities initially.

D. Allow the client to establish his own schedule.: Clients in acute mania may have poor judgment and impulsive behavior. Allowing them to establish their own schedule could lead to disorganized behavior. The nurse should offer structure to prevent this.

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A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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