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 B
Explanation
To effectively communicate with a client who speaks a different language, it is important to use alternative methods of communication. One effective method is to supplement spoken language with pictures or visual aids. This can help bridge the language barrier and enhance understanding between the nurse and the client.
Recognize that the client nodding indicates an understanding of the information: Nodding does not always indicate understanding. It could be a cultural gesture or a sign of politeness. Relying solely on nodding may lead to miscommunication and misunderstanding.
Speak to the client at an increased volume: Speaking louder does not necessarily overcome the language barrier. It may make communication more difficult and could be perceived as rude or intimidating.
Ask a family member of the client to interpret: While involving a family member may seem helpful, it is not always reliable or appropriate. Family members may not be proficient in both languages or may not fully understand medical terminology. Additionally, the client may desire privacy or may not want to burden their family members with the responsibility of interpretation.
Correct Answer is B
Explanation
The nurse should include increased cardiac output as an expected effect of digoxin when reinforcing teaching with the client. Digoxin is a positive inotropic medication that strengthens the force of contraction of the heart, resulting in increased cardiac output.
Option a, increased heart rate, is not an expected effect of digoxin. Digoxin may actually decrease heart rate by exerting a negative chronotropic effect.
Option c, decreased urinary output, is not an expected effect of digoxin. In fact, digoxin does not directly affect urinary output.
Option d, decreased potassium level, is not an expected effect of digoxin. However, digoxin can increase the risk of hypokalemia, so it is important to monitor the client's potassium levels while on the medication.
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