A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?
Steps required for dressing change
Admission vital signs
Preferred bath time
Time of last pain medication
The Correct Answer is D
The correct answer is D.
Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.
The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Infiltration is not correct: Infiltration occurs when the infused fluid or medication leaks into the surrounding tissue instead of flowing into the vein. This can lead to swelling, coolness, and pallor around the insertion site.
Choice B reason:
Extravasation is not correct: Extravasation is similar to infiltration but specifically refers to the infiltration of vesicant medications, which can cause tissue damage and necrosis.
Choice C reason:
Circulatory overload is not correct: Circulatory overload occurs when a large volume of fluid is infused too quickly, overloading the circulatory system and potentially leading to fluid overload, pulmonary edema, and other related symptoms.
Choice D reason:
Phlebitis is the appropriate fingings. The nurse should document the finding of redness and warmth around the peripheral catheter insertion site as phlebitis. Phlebitis is the inflammation of a vein, often caused by mechanical irritation, chemical irritation, or infection. In this case, the redness and warmth at the insertion site are indicative of inflammation, which is a common sign of phlebitis.
Correct Answer is D
Explanation
Answer: D. Apply support stockings.
Rationale: Support stockings can help reduce ankle edema by promoting venous return and preventing fluid accumulation in the lower extremities. Diuretics, bedrest, and fluid restriction are not recommended for pregnant clients with ankle edema as they can cause dehydration, thromboembolism, and fetal compromise.
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