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
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 A
Explanation
a. "Many people have colostomies and they live full lives."
Explanation:
The correct answer is a. "Many people have colostomies and they live full lives."
When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and offers hope to the client.
Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.
Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.
Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.
By responding with the statement that many people live full lives with colostomies, the nurse offers support, normalizes the client's experience, and promotes a positive outlook for the client's future.
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