A nurse is preparing to give 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? (Select all that apply)

Preferred bath time.

Admission vital signs.

Time of last pain medication.

Steps required for dressing change.

Answer and Explanation

Correct Answer : C,D

The correct answers are C and D.

Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.

Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.

Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.

Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.

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Correct Answer is B

Explanation

Choice A rationale:

"Request an x-ray of the preschooler's neck." - This action is not indicated for a preschooler with manifestations of respiratory syncytial virus (RSV) RSV primarily affects the respiratory system, and an x-ray of the neck would not be relevant for this condition.

Choice B rationale:

"Initiate droplet precautions." - This is the correct answer. RSV is highly contagious and primarily spreads through respiratory droplets. Initiating droplet precautions, such as wearing a mask and practicing proper hand hygiene, is essential to prevent the transmission of the virus to others in the healthcare setting.

Choice C rationale:

"Administer fluconazole to the preschooler." - Fluconazole is an antifungal medication and would not be appropriate for treating RSV, which is a viral respiratory infection. Antifungal medications are used to treat fungal infections, not viral ones.

Choice D rationale:

"Monitor the preschooler's urine for protein." - Monitoring urine for protein is not relevant to the care of a preschooler with RSV. This action is more suitable for conditions that may affect the kidneys or urinary system but not RSV, which primarily affects the respiratory system.

A. Raise the entire bed while bathing the client to reduce back strain B. Report any drainage observed around the GT insertion site C. Keep the head of the bed raised while the tube feeding is infusing D. Use plenty of pillows to position the client on the side after bathing.

Correct Answer is C

Explanation

Answer isc. Keep the head of the bed raised while the tube feeding is infusing.

The client has a gastrostomy tube (GT), which is a tube inserted through the abdomen into the stomach for feeding purposes1.The PN should instruct the UAP to keep the head of the bed raised at least 30 degrees while the tube feeding is infusing, to prevent aspiration of the feed into the lungs2.Aspiration can cause pneumonia, which is a serious complication that can be fatal3.

a. Raising the entire bed while bathing the client to reduce back strain is not the most important instruction, because it does not address the risk of aspiration. The PN should also consider the client’s comfort and safety when adjusting the bed height. b. Reporting any drainage observed around the GT insertion site is not the most important instruction, because it is not directly related to the tube feeding. Drainage may indicate infection or leakage of the feed, which should be reported and managed accordingly. d. Using plenty of pillows to position the client on the side after bathing is not the most important instruction, because it is not specific to the tube feeding. Positioning the client on the side may help prevent pressure ulcers and improve circulation, but it does not prevent aspiration.

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A nurse is preparing to give 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? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has a continuous feeding via gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Correct Answer is C

Explanation

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