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 C

Explanation

- A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.

- B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.

- C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.

- D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.

fluid overload

A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

Correct Answer is C

Explanation

Respiratory acidosis.

Rationale:

A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45). - C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).

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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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Correct Answer is C

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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?