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 not include in the change-of-shift report?

The last time the provider evaluated the client

The client's most recent ventilator settings

The time of the client's last dose of pain medication

The frequency in which the client presses the call button

None

Answer and Explanation

The Correct Answer is C

a. The last time the provider evaluated the client: This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
b. The client's most recent ventilator settings: The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
c. The time of the client's last dose of pain medication: This helps manage the client's pain effectively and prevent potential withdrawal symptoms.

d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.

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Correct Answer is D

Explanation

Choice A rationale:

Human papillomavirus (HPV) vaccination is recommended for adolescents and young adults to prevent HPV-related cancers and diseases. However, in the context of older adults, especially those who are not previously vaccinated, the priority shifts to other immunizations that are more relevant to their age group.

Choice B rationale:

Rotavirus vaccination is administered to infants to protect against rotavirus infections, which can cause severe diarrhea and dehydration. It is not a priority immunization for older adults. Older adults are at higher risk for certain diseases, and their immunization focus should be on vaccines that prevent those specific conditions.

Choice C rationale:

Diphtheria, tetanus, and acellular pertussis (DTaP) vaccination is essential for children and adults, especially for those who have not received a complete series of vaccinations. However, the question specifies older adults, and DTaP is typically administered to children. While it is crucial for healthcare providers and family members to stay up-to-date with their vaccinations, other immunizations are more pertinent for older adults.

Choice D rationale:

Herpes zoster vaccination (shingles vaccine) is recommended for adults aged 50 years and older. Herpes zoster is a painful rash caused by the reactivation of the varicella-zoster virus, which also causes chickenpox. Older adults are at higher risk of developing shingles, and vaccination can reduce the likelihood of the disease and its complications. Therefore, the nurse should recommend the herpes zoster vaccine to the group of older adults as it aligns with their age and addresses a specific health risk they face.

A. "I will change your IV tubing once every 48 hours." B. "Abdominal distention is an expected effect of this therapy." C. "I will need to check your gastric residual before administering feedings." D. "I will need to measure your weight daily."

Correct Answer is D

Explanation

Parental Nutrition

- A is incorrect because IV tubing for total parenteral nutrition should be changed every 24 hours to prevent infection.

- B is incorrect because abdominal distention is not an expected effect of total parenteral nutrition. It could indicate a complication such as fluid overload or bowel obstruction.

- C is incorrect because gastric residual is not relevant for total parenteral nutrition, which bypasses the gastrointestinal tract.

- D is correct because weight measurement is an important indicator of fluid balance and nutritional status for clients receiving total parenteral nutrition.

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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 not include in the change-of-shift report?

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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 not include in the change-of-shift report?