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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. This choice is incorrect because verapamil and TPN do not have a significant food and medication interaction. Verapamil is a calcium channel blocker that can lower blood pressure and heart rate, while TPN is a form of intravenous nutrition that provides calories, electrolytes, vitamins, and minerals. The nurse should monitor the client's vital signs and blood glucose levels, but there is no need to intervene to prevent an interaction.

B. This choice is incorrect because phenytoin and milkshakes do not have a significant food and medication interaction. Phenytoin is an anticonvulsant that can decrease the absorption of some vitamins, such as folic acid and vitamin D, but milkshakes are not a major source of these nutrients. The nurse should encourage the client to eat a balanced diet and take supplements as prescribed, but there is no need to intervene to prevent an interaction.

C. This choice is incorrect because potassium-rich foods and furosemide do not have a significant food and medication interaction. Furosemide is a loop diuretic that can cause hypokalemia, or low potassium levels, but potassium-rich foods can help prevent this complication. The nurse should monitor the client's electrolyte levels and fluid balance, but there is no need to intervene to prevent an interaction.

D. This choice is correct because MAOIs and cheeseburgers have a significant food and medication interaction. MAOIs are antidepressants that can cause hypertensive crisis, or dangerously high blood pressure, if the client consumes foods that contain tyramine, such as aged cheeses, cured meats, fermented foods, and beer. The nurse should intervene to prevent the client from eating a cheeseburger and educate the client about avoiding tyramine-containing foods while taking MAOIs.

A. "I can designate my partner as my health care surrogate." B. "I am only 40 years old, so I don't need to worry about this yet." C. “I will need a lawyer's help to draw up the documents." D. “ I understand that my family can alter my advance directives if I become incapacitated."

Correct Answer is A

Explanation

A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.

B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.

C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.

D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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