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.
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Correct Answer is B
Explanation
A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.
B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.
C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.
D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.
Correct Answer is D
Explanation
Choice A reason:
Increased urinary frequency Increased urinary frequency is not a typical adverse effect of sertraline. However, some individuals may experience changes in urinary habits due to various factors, but it is not directly related to sertraline use.
Choice B reason
Dry cough Dry cough is not a commonly reported adverse effect of sertraline. Cough is not a typical symptom associated with this medication.
Choice C reason
Metallic taste in the mouth While some individuals may experience changes in taste as a side effect of sertraline, a metallic taste in the mouth is not one of the commonly reported adverse effects. Taste changes are usually mild and temporary.
Choice D reason
Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder. While most individuals tolerate sertraline well, it can cause certain adverse effects, and excessive sweating (also known as diaphoresis) is one of them.
Excessive sweating is a common side effect of sertraline and other SSRIs. It can manifest as increased sweating during the day or night, even in cooler environments. The degree of sweating can vary among individuals, and some may experience it more than others.
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