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.
His partner has been visiting.
He is voiding adequately.
He is allergic to sulfa.
The Correct Answer is D
Choice A rationale
He appears anxious about the transfer provides subjective information about the client's emotional state. While important, it's not essential for the transfer report which typically focuses on objective, actionable data.
Choice B rationale
His partner has been visiting is valuable for understanding the client's support system, but it does not directly affect the client's clinical care during transfer.
Choice C rationale
He is voiding adequately offers relevant information about the client's bodily function, important for ongoing care but not as critical as allergy information.
Choice D rationale
He is allergic to sulfa provides essential medical information that can affect the client's treatment plan. Knowing allergies is crucial to prevent adverse reactions to medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Using a narrower cuff can result in an inaccurate blood pressure reading by providing artificially high values due to increased pressure on a smaller surface area.
Choice B rationale
Requesting a prescription for an antihypertensive medication is premature without verifying the accuracy of the initial blood pressure measurement and considering other factors that might have influenced the reading.
Choice C rationale
Measuring the client's blood pressure in the other arm can help confirm the initial reading. Differences in readings between arms can occur, and a second measurement ensures accuracy and proper assessment.
Choice D rationale
Deflating the cuff faster when repeating the blood pressure measurement can lead to inaccurate readings. The cuff should be deflated at a standard rate to ensure reliability and accuracy in the measurement. .
Correct Answer is B
Explanation
Choice A rationale
Standing with the crutch tips against the feet is incorrect. Proper crutch placement involves positioning the crutches slightly forward and to the side of the feet to provide stability and prevent tripping.
Choice B rationale
Bearing weight on the unaffected leg is the correct instruction for using the three-point gait. This technique allows the client to move the crutches and the affected leg together while bearing weight on the unaffected leg, promoting balance and mobility.
Choice C rationale
Keeping the crutches at the level of the axillae is incorrect. Crutches should be positioned with a 1-2 inch gap below the axillae to prevent nerve damage and ensure proper support.
Choice D rationale
Holding the arms straight when walking is incorrect. The elbows should be slightly bent to allow for comfortable movement and better control of the crutches.
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