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 D

A. The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.

B. The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.

C. The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.

D. The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.

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Correct Answer is A

Explanation

A: A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B: A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C: A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D: A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

A. Oxygen saturation level B. Tremors C. Respiratory rate D. Heart rate E. Current level of consciousness F. Chronic health condition

Correct Answer is ["A","C","E"]

Explanation

Since the client is experiencing upper chest discomfort and coughing up sputum, it is important to assess their oxygen saturation level. This finding can provide vital information about the client's respiratory status and the adequacy of their oxygenation.

The client's report of upper chest discomfort and coughing up thick clear sputum should prompt an assessment of their respiratory rate. Abnormal respiratory rates may indicate respiratory distress or compromise, which requires immediate attention.

Assessing the client's current level of consciousness is crucial, as any sudden changes in their mental status may indicate a serious underlying issue. Since the client has a history of Parkinson's disease and reported "feeling bad," it is important to evaluate their neurological status promptly.

The other options listed (tremors, heart rate, and chronic health condition) may also require follow-up, but they are not the most immediate concerns in this situation.

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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?