A nurse is providing a change-of shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?
Client was nauseated immediately after surgery.
Client's pain relieved by position change.
Checked for peripheral IV blood return prior to antibiotic.
Client provided with breakfast tray at 0800.
The Correct Answer is B
A. Client was nauseated immediately after surgery: While postoperative nausea is important to document, it is an event that occurred in the past and may not reflect the client’s current status 36 hours after surgery.
B. Client’s pain relieved by position change: This information is critical as it reflects the current effectiveness of nonpharmacologic pain management strategies and guides ongoing care for comfort.
C. Checked for peripheral IV blood return prior to antibiotic: This is a routine nursing task that was completed. While important for safe medication administration, it's a procedural detail of a completed task and not usually included in a concise shift report.
D. Client provided with breakfast tray at 0800: Although documenting nutrition is important, the exact timing of meal delivery is less significant than clinical status information during shift handoff.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Palpate the pulse distal to the cast: Assessing circulation is the priority after cast application to detect signs of compartment syndrome or impaired perfusion. A diminished or absent distal pulse may indicate an emergency requiring immediate intervention.
B. Place an ice pack over the cast: Applying ice can reduce swelling and discomfort in the first 24 to 48 hours, but it is a supportive measure. It should be done after confirming that circulation is intact.
C. Teach the client to keep the cast clean and dry: Client education is important for long-term cast care, but it is not an immediate priority following application. Circulatory checks take precedence to prevent complications.
D. Position the casted extremity on a pillow: Elevation helps minimize swelling and promote venous return, but it should be done after confirming that blood flow is adequate and not compromised by the cast.
Correct Answer is B
Explanation
A. Decreased temperature: Vomiting and diarrhea usually cause dehydration, but they do not typically lower body temperature. Infants may have a normal or slightly elevated temperature if an infection is present.
B. Oliguria: Oliguria, or reduced urine output, is a key sign of dehydration in infants. Fluid loss from vomiting and diarrhea leads to decreased kidney perfusion, causing the kidneys to conserve water and produce less urine.
C. Bulging anterior fontanel: A bulging anterior fontanel indicates increased intracranial pressure and is not a sign of dehydration. In contrast, dehydration often causes a sunken fontanel due to decreased fluid volume.
D. Hypertension: Dehydration usually causes low blood pressure in infants because of decreased circulating blood volume. Hypertension is not expected in this situation and would suggest a different underlying issue.
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