A nurse is providing change-of-shift report for a client who has heart failure. Which of the following information should the nurse notinclude in the report?
The client's most recent blood pressure reading was 110/60 mm Hg.
The client's morning laboratory results included a potassium level of 4.9 mg/dL.
The client has +2 pitting edema in the lower extremities.
The client's partner assisted them with their meal tray.
The Correct Answer is D
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading, morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Yogurt is a beneficial food for individuals with IBS for several reasons: Yogurt contains live beneficial bacteria, known as probiotics, which can help regulate the balance of gut bacteria. Probiotics may improve digestive health and reduce symptoms such as bloating, gas, and diarrhea in some individuals with IBS. Yogurt is a good source of calcium, which is an essential nutrient for overall health and plays a role in maintaining normal digestive function.
Ice cream is not typically recommended for individuals with IBS. It contains high amounts of fat and lactose, which can worsen symptoms such as bloating, gas, and diarrhea in some individuals with IBS. Moreover, some people with IBS may be sensitive to dairy products.
Honey is generally well-tolerated by individuals with IBS. However, it does not offer specific benefits for managing IBS symptoms. Its inclusion in the diet would depend on individual preferences and tolerances.
Watermelon is a low-FODMAP fruit, which means it is generally well-tolerated by individuals with IBS. It can be a refreshing and hydrating option. However, its inclusion in the diet would depend on individual preferences and tolerances.
Correct Answer is C
Explanation
c. Ketones positive.
Explanation:
Ketones in the urine can be an indication of diabetic ketoacidosis (DKA) or other metabolic disorders. It is abnormal and should be reported to the healthcare provider for further evaluation and management. Positive ketones suggest that the body is breaking down fats for energy instead of using glucose, which can be a sign of inadequate insulin levels or utilization.
Options a, b, and d are within normal ranges or do not indicate an immediate concern. A specific gravity of 1.020 is within the normal range and indicates appropriate urine concentration. Uric acid levels of 475 mg/24 hr are not mentioned as abnormal or concerning in the context provided. Nitrites negative indicates the absence of nitrites in the urine, which is a normal finding and indicates the absence of a urinary tract infection.
However, it's important to note that clinical judgment should always be exercised, and the nurse should consider the patient's overall clinical presentation and history when interpreting laboratory results and making decisions regarding reporting to the provider.
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