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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
c. Ringing in the ears.
Explanation:
Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally well-tolerated, there can be potential side effects or adverse reactions that the adolescent should monitor and report to the healthcare provider. One of the more significant adverse effects associated with cephalosporins, including cefazolin, is ototoxicity, which can manifest as ringing in the ears (tinnitus). It is important for the adolescent to be aware of this potential side effect and promptly report it to the healthcare provider.
Options a, b, and d are not specifically associated with cefazolin and would not be the priority findings to monitor and report. Constipation is a less common side effect of cefazolin, and if it occurs, it can usually be managed with supportive measures or adjustments in diet and hydration. Elevated skin patches are not typically associated with cefazolin use. Depression is not a common side effect of cefazolin and would require further assessment and evaluation, but it is not directly related to the medication itself.
Correct Answer is C
Explanation
A nurse collecting data from a client who reports having diarrhea for the past 3 days should identify that muscle weakness is a symptom of hypokalemia. Hypokalemia is a condition in which the blood potassium level is low and can be caused by excessive fluid loss through diarrhea. Potassium helps regulate muscle contractions, so when blood potassium levels are low, muscles may produce weaker contractions which result in muscle weakness.
The other options are not typical symptoms of hypokalemia.
a) Pitting edema is not a typical symptom of hypokalemia.
b) Diplopia is not a typical symptom of hypokalemia.
d) Hyperactive bowel sounds are not a typical symptom of hypokalemia.
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