A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

"The client reports pain is reduced when he is positioned on his side."

"The client received the prescribed antibiotic every 8 hours."

"The client's mother died 4 years ago from breast cancer."

"The client's partner visited earlier today for 2 hours."

Answer and Explanation

The Correct Answer is A

A. Correct. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.

B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.

C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.

D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.

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Correct Answer is A

Explanation

A. Correct. The plantar Babinski reflex is elicited by stroking the sole of the foot along the lateral aspect, from the heel to the ball of the foot. The nurse's instruction to the client is accurate.
B. Tapping the knee is related to the knee jerk reflex, not the Babinski reflex.
C. Tapping the back of the heel does not elicit the plantar Babinski reflex.
D. Testing elbow extension is unrelated to the Babinski reflex.

A. Witness the client signing a consent for transfusion. B. Obtain a large bore IV catheter. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Explain to the client that transfusion reactions are not serious.

Correct Answer is ["A","B","C"]

Explanation

A. Correct. The nurse should witness the client signing a consent form for blood transfusion.
Informed consent is necessary for any medical procedure.
B. Correct. A large bore IV catheter is required for blood transfusion to ensure the smooth flow of blood and prevent clotting.
C. Correct. Two nurses should confirm the information on the blood label, including the client's identification and the blood type, to prevent errors.
D. Incorrect. Transfusion tubing is typically flushed with normal saline before attaching it to the patient. Flushing with dextrose 5% in water is not necessary or recommended.
E. Incorrect. It's important for the nurse to educate the client about potential transfusion reactions, as some reactions can indeed be serious. Providing accurate information helps the client understand the importance of monitoring for any signs of a reaction.

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A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following Instructions should the nurse give to prepare the client for this test?

Correct Answer is A

Explanation

The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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