A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?
The frequency in which the client presses the call button
The client's most recent ventilator settings
The time of the client's last dose of pain medication
The last time the provider evaluated the client
The Correct Answer is C
A. The frequency in which the client presses the call button is not a priority for the change-of-shift report, as it does not indicate the level of pain or comfort of the client. This choice is incorrect.
B. The client's most recent ventilator settings are not applicable, as the client was weaned from mechanical ventilation and no longer requires it. This choice is incorrect.
C. The time of the client's last dose of pain medication is important for the change-of-shift report, as it helps to ensure continuity of care and prevent under- or over-medication of the client. This choice is correct.
D. The last time the provider evaluated the client is not relevant for the change-of-shift report, as it does not reflect the current status of the client. This choice is incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
D: Incorrect. Cream cheese is a dairy product that contains tyramine, which can interact with phenelzine and cause a hypertensive crisis.
E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
Correct Answer is A
Explanation
A. This client is at risk of harming themselves by removing the IV line, which could cause bleeding, infection, or loss of medication. This is a priority issue that requires immediate intervention by the nurse.
B. This client is experiencing a common side effect of pain medication, which can be managed by administering antiemetics, fluids, or changing the medication. This is not a life-threatening issue and can be addressed after attending to the client in choice A.
C. This client has a chronic condition that requires regular dialysis, but they are not in acute distress at this time. They should be monitored for signs of fluid overload, electrolyte imbalance, or infection, but they are not a priority over the client in choice A.
D. This client has a psychosocial need that should be respected and supported by the nurse, but it is not an urgent issue that requires immediate attention. The nurse can arrange for a visit from the chaplain after attending to the client in choice A.
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