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 D
Explanation
Choice A rationale
While checking recent medication administration is important, it is not the immediate priority when a client is experiencing shortness of breath. Immediate actions should focus on assessing and improving the client's oxygenation status.
Choice B rationale
Reviewing the client’s most recent SaO2 level is useful, but not the first action to take when there is an immediate concern for the client’s oxygenation. Addressing the current low SaO2 level takes precedence.
Choice C rationale
Notifying the charge nurse is necessary, but the nurse should first attempt to quickly re-evaluate the client’s condition and try simple interventions to improve oxygenation, such as having the client cough and clear their throat.
Choice D rationale
Rechecking the SaO2 level after having the client cough and clear their throat is the appropriate first action. This can help determine if the low SaO2 reading is due to a temporary obstruction, such as mucus, and allows for a more accurate assessment of the client's respiratory status. .
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Choice A rationale:
While hoarseness can be a symptom of aspiration pneumonia, it is not a direct cause. Hoarseness alone does not necessarily lead to aspiration pneumonia.
Choice B rationale:
Coughing when eating is a direct risk factor for aspiration pneumonia. Coughing indicates that food or liquid may be entering the airway, which can lead to aspiration pneumonia.
Choice C rationale:
Dysphagia (difficulty swallowing) can be a risk factor for aspiration pneumonia, but in this case, the client's symptoms (coughing when eating and hoarseness) are more directly associated with aspiration pneumonia.
Choice D rationale:
While coughing when eating can be a symptom of dysphagia, the primary concern here is the risk of aspiration pneumonia due to the same symptom.
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