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 C
Explanation
A. Grilled hot dog with French fries: Hot dogs may contain fillers with gluten, and cross-contamination in fries is common if shared fryers are used, making this choice unsafe.
B. Oatmeal cookie with raisins: Unless the oats are certified gluten-free, they may be contaminated with gluten during processing, posing a risk for children with celiac disease.
C. Baked sweet potato with cinnamon: Sweet potatoes are naturally gluten-free, and cinnamon is safe as well. This option provides a nutritious and safe food for a child with celiac disease.
D. Hazelnut butter on wheat toast: Wheat toast contains gluten and should be strictly avoided in individuals with celiac disease, even if the topping is gluten-free.
Correct Answer is A
Explanation
A. Stop the procedure: Stopping the blood transfusion immediately is the priority to prevent further exposure to the potentially harmful blood product causing the wheezing. This action helps minimize the risk of progression to a more severe transfusion reaction or anaphylaxis.
B. Administer an antihistamine: Antihistamines may relieve allergic symptoms but should only be given after the transfusion is stopped and the client is assessed. Administering medication without stopping the transfusion first could worsen the reaction.
C. Administer oxygen: Providing oxygen supports the client’s respiratory function during wheezing, which may indicate hypoxia. Oxygen administration is important but secondary to stopping the transfusion to eliminate the cause.
D. Initiate an infusion of 0.9% sodium chloride using new tubing: Starting a saline infusion with new tubing helps maintain IV access and prevent clotting after stopping the transfusion. This action is necessary but follows stopping the transfusion as the first priority.
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