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."
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will take the medication in the morning." Metformin extended-release can be taken once daily, but it is usually recommended with the evening meal to improve gastrointestinal tolerance.
B. "I will take the medication on an empty stomach." This is incorrect because metformin should be taken with food to reduce gastrointestinal side effects such as nausea and diarrhea.
C. "I will avoid crushing this medication." This is correct because extended-release tablets should not be crushed, split, or chewed, as this can alter the drug’s release mechanism.
D. "I will expect to gain weight." Metformin is not associated with weight gain; in fact, it may cause modest weight loss in some clients.
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
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