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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Related Questions
Correct Answer is A
Explanation
A. Discuss the client's food preferences with the hospital's dietitian: Collaborating with the dietitian allows for personalization of the prescribed diet while maintaining its nutritional and therapeutic goals. This approach respects the client’s preferences and promotes adherence to the diabetes management plan.
B. Allow the client's family to bring food from home for the client: While family involvement is valuable, food from home may not comply with dietary restrictions and could interfere with blood glucose control unless reviewed by a dietitian or provider.
C. Request the provider change the client's prescribed diet: The issue is not the suitability of the prescribed diet but rather the client’s acceptance of it. Changing the prescription without first exploring preferences is premature.
D. Offer the client's meals on a different schedule: Changing meal timing alone does not address the client’s refusal to eat. Understanding and integrating food preferences is more effective in encouraging intake and supporting glycemic control.
Correct Answer is B
Explanation
A. Administer propranolol IV to the client: Propranolol is a beta-blocker used to treat hypertension and certain cardiac conditions. It is not indicated for sudden nausea during pregnancy and could be harmful if administered without cause.
B. Position the client on her side: At 36 weeks, the gravid uterus can compress the inferior vena cava when the client lies flat, reducing venous return and causing supine hypotensive syndrome, which often presents as nausea. Turning the client to her side relieves pressure and restores circulation.
C. Ask the client to increase her daily calcium intake: Calcium is important during pregnancy, especially for bone health, but increasing intake is not an acute intervention for nausea caused by positional blood flow issues.
D. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers assess fetal position but do not address the client’s immediate symptom of nausea, which may indicate compromised circulation from lying supine. Position change is the priority action.
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