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
The correct answer and explanation is:
c. Denial
The nurse should identify that the client is experiencing the stage of denial in the grief process. Denial is a common psychological defense mechanism that individuals may exhibit when faced with a stressful or overwhelming situation, such as the prospect of open heart surgery. It involves a refusal to accept or acknowledge the reality of the situation. In this case, the client's statement of being confident to go home shortly after surgery demonstrates a denial of the potential challenges and recovery process associated with such a procedure.
Explanation for the other options:
A . Anger: Anger is a stage of grief characterized by feelings of resentment, frustration, and hostility. It is common for individuals to experience anger as part of the grief process, but the client's statement does not indicate anger.
B. Depression: Depression is another stage of grief marked by feelings of sadness, hopelessness, and loss. While it is normal for individuals to experience some level of anxiety or sadness before undergoing surgery, the client's statement does not specifically reflect depression.
d. Acceptance: Acceptance is the final stage of grief, where individuals come to terms with their situation and find a sense of peace or resolution. The client's statement indicates a lack of acceptance as they are denying the potential impact of the surgery and its recovery process.
Correct Answer is B
Explanation
b. "I should join a support group to help me be successful."
The statement that indicates an understanding of smoking cessation teaching is option b: "I should join a support group to help me be successful." Joining a support group is a beneficial strategy for quitting smoking as it provides social support, encouragement, and shared experiences with others who are also trying to quit.
Option a is incorrect because using nicotine patches does not allow for continued smoking as it delivers nicotine without the harmful effects of smoking.
Option c is incorrect because nicotine replacement therapy (NRT) is a safe and effective method to manage nicotine withdrawal and does not cause cancer.
Option d is incorrect because varenicline is a medication that helps reduce nicotine cravings and withdrawal symptoms, and it does not make a person addicted to nicotine.
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