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. Weak cry
Explanation: In the context of a newborn with shoulder dystocia, a weak cry can be an indication of pain. Newborns communicate their discomfort or pain through crying, and a weak cry may suggest that the newborn is experiencing pain or distress.
Option a, lip-smacking, is not necessarily a specific indication of pain in this situation. Lip-smacking can
occur due to various reasons and may not solely indicate pain.
Option b, a stiff posture, may be more indicative of muscle tension or rigidity rather than pain in this
scenario.
Option d, tongue-darting, is not a specific indicator of pain in this context. Tongue-darting is a common behavior in newborns and may not be directly related to pain.
By recognizing a weak cry as a potential indication of pain in the newborn with shoulder dystocia, the nurse
can provide appropriate interventions and support to manage the newborn's pain and discomfort.
Correct Answer is C
Explanation
Answer: C. Change the perineal pad with each void.
Rationale:
A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.
B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.
C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.
D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.
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