A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

"The client received morphine around lunch."

"The client had a lung biopsy 1 hour ago."

"Vital signs were obtained every 4 hours."

"The client's partner is at their bedside."

Answer and Explanation

The Correct Answer is B

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

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Correct Answer is A

Explanation

A. Measure and record the client's leg circumferences daily. This is correct because measuring leg circumference helps assess for changes in swelling and monitor the progression or improvement of deep-vein thrombosis.
B. Place the client with their knees in a sharply flexed position. This is incorrect because sharply flexing the knees can impede blood flow and increase the risk of clot formation. The client should be encouraged to keep their legs extended and slightly elevated.
C. Monitor the client's RBCs every 4 hr. This is incorrect because deep-vein thrombosis does not typically require frequent RBC monitoring. Instead, coagulation studies such as PT, aPTT, and INR are more relevant.
D. Administer warfarin PO daily. This is incorrect because warfarin is contraindicated during pregnancy due to its teratogenic effects. Instead, low-molecular-weight heparin or unfractionated heparin is the preferred anticoagulant during pregnancy.

A. Decrease the IV flow rate. B. Monitor fetal heart rate C. Administer ampicillin IV D. Place client in left lateral position. E. Request a prescription for ephedrine.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Essential Interventions:

Monitor fetal heart rate
Administer ampicillin IV
Place client in left lateral position
Request a prescription for ephedrine

Contraindicated Intervention:

Decrease the IV flow rate

Rationale:

Monitor fetal heart rate (Essential): Epidural anesthesia can cause maternal hypotension, leading to decreased uteroplacental perfusion. Continuous fetal heart rate monitoring ensures the fetus is tolerating labor well.
Administer ampicillin IV (Essential): The client tested positive for Group B Streptococcus (GBS) at 37 weeks, requiring prophylactic IV antibiotic administration during labor to prevent neonatal infection.
Place client in left lateral position (Essential): This position improves venous return, enhances placental perfusion, and prevents hypotension caused by epidural anesthesia.
Request a prescription for ephedrine (Essential): Epidural anesthesia can cause maternal hypotension, and ephedrine is a vasopressor that can help restore blood pressure if needed.
Decrease the IV flow rate (Contraindicated): IV fluids should be maintained or increased to prevent hypotension, a common side effect of epidural anesthesia. Reducing the IV rate could exacerbate hypotension and fetal distress.

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A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 32 weeks of gestation and has deep-vein thrombosis. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is in active labor. Exhibits The nurse is caring for a client following the insertion of an epidural. For each nursing intervention, click to specify if the intervention is essential or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

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