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 B

Explanation

A. Applying suction only during catheter removal is correct because continuous suction while inserting the catheter can cause tissue trauma and hypoxia. Intermittent suctioning during withdrawal prevents damage to the tracheal mucosa.

B. Suctioning for 30 seconds exceeds the recommended time limit, which is typically 10–15 seconds per pass for adults. Prolonged suctioning can cause hypoxia, bradycardia, and tissue trauma, making it unsafe for the client.

C. Preoxygenating with 100% oxygen before suctioning helps prevent hypoxia during the procedure. This is a standard safety measure to maintain adequate oxygen saturation levels.

D. Auscultating breath sounds before and after suctioning allows assessment of airway clearance and lung status. This step ensures that secretions have been effectively removed and helps identify any complications early.

A. Exercise when insulin is at its peak action. B. Eat a piece of fruit before exercising. C. Inject additional insulin before exercising. D. Avoid protein before exercising.

Correct Answer is B

Explanation

A. Exercising when insulin is at its peak action is incorrect. Exercising during peak insulin activity increases the risk of hypoglycemia. It is best to exercise when insulin levels are more stable, such as 1 to 2 hours after a meal.

B. Eating a piece of fruit before exercising is correct. A small carbohydrate snack before exercise helps prevent hypoglycemia, especially for clients with type 1 diabetes. The body requires glucose for energy, and exercise can lower blood sugar levels rapidly.

C. Injecting additional insulin before exercising is incorrect. Exercise naturally lowers blood glucose, so adding extra insulin increases the risk of hypoglycemia. Instead, insulin doses may need to be adjusted downward based on activity levels.

D. Avoiding protein before exercising is incorrect. While carbohydrates are the primary concern, protein intake before exercise is not harmful and can support muscle function. However, the focus should be on carbohydrate intake to maintain blood glucose levels.

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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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