A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

"He appears anxious about the transfer."

"He is allergic to sulfa."

"His partner has been visiting."

"He is voiding adequately."

Answer and Explanation

The Correct Answer is B

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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Correct Answer is D

Explanation

Choice A Reason:

"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.

Choice B Reason:

"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.

Choice C Reason:

"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.

Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.

Choice D Reason:

"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.

A. Use a filter needle to aspirate the medication B. Add 0.5 ml of diluent to the medication, C. Cleanse the tip of the ampule with an alcohol swab after opening. D. Inject air into the ampule prior to drawing the medication into a syringe.

Correct Answer is A

Explanation

Choice A Reason:

A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.

Choice B Reason:

Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.

Choice C Reason:

The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.

Choice D Reason:

Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.

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A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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