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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Almonds are not typically associated with latex allergy or cross-sensitivity. Latex cross-reactivity is more commonly seen with certain fruits such as bananas, avocados, kiwis, and chestnuts.
Choice B rationale:
Bananas are known to be cross-reactive with latex allergy. Individuals allergic to latex are more likely to have allergies to certain fruits, including bananas. This cross-sensitivity occurs due to the structural similarity between latex proteins and proteins found in these fruits.
Choice C rationale:
Hazelnuts are not commonly associated with latex cross-reactivity. While some individuals with latex allergy may also be allergic to hazelnuts, it is not a high-risk food in the context of latex cross-sensitivity.
Choice D rationale:
Strawberries are not typically associated with latex allergy or cross-reactivity. Latex cross-reactivity is more commonly seen with fruits like bananas, avocados, kiwis, and chestnuts. Strawberries are not among the high-risk foods for individuals with latex allergy.
Correct Answer is D
Explanation
Choice A rationale:
Protective environment isolation precautions are used for immunocompromised patients to protect them from infections in the environment. It is not the appropriate precaution for a patient with bacterial meningitis, which is spread through respiratory droplets.
Choice B rationale:
Airborne precautions are used for diseases that are spread through the air and require a negative pressure room. Examples include tuberculosis and chickenpox. Bacterial meningitis is spread through respiratory droplets, not airborne transmission.
Choice C rationale:
Contact precautions are used for diseases that are spread by direct or indirect contact. Examples include MRSA and Clostridium difficile. Bacterial meningitis is primarily spread through respiratory droplets, not direct contact.
Choice D rationale:
Droplet precautions are used for diseases that are spread by respiratory droplets, such as influenza and bacterial meningitis. Patients with bacterial meningitis should be placed in a private room and wear a mask, and healthcare providers should wear a mask and eye protection when within 3 feet of the patient. This precaution helps prevent the spread of respiratory droplets containing the bacteria.
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