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.
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Related Questions
Correct Answer is C
Explanation
Ciprofloxacin is an antibiotic commonly prescribed for the treatment of various bacterial infections. It belongs to a class of medications known as fluoroquinolones. One potential side effect of ciprofloxacin is increased sensitivity to sunlight, which can lead to a higher risk of sunburn. Therefore, it is important for the client to take precautions, such as using sunscreen, wearing protective clothing, and avoiding excessive sun exposure while taking this medication.
"Take an antacid if the medication causes gastrointestinal upset": Ciprofloxacin can be taken with or without food, but it should not be taken with antacids, calcium supplements, or other products containing aluminum, magnesium, or calcium, as they can interfere with the absorption of the medication. If gastrointestinal upset occurs, it is generally recommended to take the medication with food to minimize this side effect.
"Restrict your daily fluid intake while taking this medication": There is no need to restrict fluid intake while taking ciprofloxacin unless specifically instructed by the healthcare provider.
Adequate hydration is important to maintain overall health and prevent potential complications.
"Expect to experience diarrhea while taking this medication": Diarrhea can be a potential side effect of ciprofloxacin, but it is not a universal experience for all individuals taking the medication. It is more appropriate to inform the client about the potential side effects of ciprofloxacin, including gastrointestinal upset, and to encourage them to report any significant or persistent symptoms to their healthcare provider
Correct Answer is D
Explanation
The nurse should recognize that the client needs a referral for diabetic education when the client lists sweating, shaking, and palpitations as symptoms of hyperglycemia. These symptoms are actually associated with hypoglycemia, not hyperglycemia. Hyperglycemia is characterized by symptoms such as increased thirst, frequent urination, and fatigue.
Option a is incorrect because drawing up regular insulin before NPH when demonstrating injection technique is the correct procedure.
Option b is incorrect because seeing a primary care provider to treat corns on the feet is an appropriate action for a client with diabetes.
Option c is incorrect because treating hypoglycemic reactions with 15 g of carbohydrates is the recommended treatment.
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