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 B

Explanation

- A. Chest x-ray is not correct because it is not related to valproic acid therapy or its adverse effects.

- B. Serum liver enzyme levels is correct because valproic acid can cause hepatotoxicity and liver function tests should be monitored regularly.

- C. ABGS is not correct because it is not indicated for valproic acid therapy or its adverse effects.

- D. Urine culture and sensitivity is not correct because it is not related to valproic acid therapy or its adverse effects.

A. The client is taking numerous deep, measured breaths B. The client is calmly telling their partner that "the staff here is so controlling C. The client is sitting with their head in their hands and appears to be crying D. The client is pacing around the chair in which their partner is sitting

Correct Answer is D

Explanation

The client is pacing around the chair in which their partner is sitting.

Rationale:

A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.

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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 caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

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Explanation

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Correct Answer is D

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