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

Answer and Explanation

The Correct Answer is C

Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:

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

Here's why:
a. The frequency in which the client presses the call button: While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
b. The client's most recent ventilator settings: Since the client is already weaned from ventilation, this information is no longer pertinent.
d. The last time the provider evaluated the client: While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
c. The time of the client's last dose of pain medication: Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.

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Correct Answer is C

Explanation

A. Incorrect. A 1-inch needle may not be long enough to reach the muscle layer in an obese client, which may result in subcutaneous injection and reduced absorption of the medication.
B. Incorrect. A 45° angle may not be appropriate for an IM injection, as it may cause the needle to enter at an oblique angle and miss the muscle layer or hit a bone or nerve.
C. Correct. The ventrogluteal site is preferred for IM injections in obese clients, as it has less subcutaneous fat and a large muscle mass that can accommodate larger volumes of medication.
D. Incorrect. Pinching the skin up during injection may cause the needle to enter at a shallow angle and deposit the medication in the subcutaneous tissue instead of the muscle layer.

A. Contact the facility's ethics committee B. Obtain consent from the client's employer C. Limit care to comfort measures D. Proceed with provision of medical care

Correct Answer is D

Explanation

Proceed with provision of medical care.

A. Contact the facility's ethics committee: This is incorrect because it is not an urgent action and it does not address the client's immediate needs. The ethics committee can be consulted later if there are ethical dilemmas or conflicts regarding the client's care.
B. Obtain consent from the client's employer: This is incorrect because it is not a valid source of consent. The employer has no legal or ethical authority to make decisions for the client, unless they are also a designated surrogate or proxy.
C. Limit care to comfort measures: This is incorrect because it does not meet the standard of care for an emergency situation. The nurse has a duty to provide life-saving interventions for a client who is unconscious and requires emergency medical procedures, unless there is evidence of a valid advance directive that states otherwise.
D. Proceed with provision of medical care: This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.

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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 include in the change-of-shift report?

Nursing Test Bank

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A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

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Correct Answer is D

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