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After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.

Appointment the next day

Low oxygen saturation

Previous injection drug user and alcohol misuse

Has productive cough severe enough to keep her awake

Marital status

Fever is present.

Elevated temp. pulse, and respiratory rate

Diagnosis pneumonia

Daughter's name

Answer and Explanation

Correct Answer : B,C,D,G,H

Low oxygen saturation: Low oxygen saturation indicates a potential respiratory compromise and should be addressed promptly to ensure adequate oxygenation and prevent further deterioration.

Previous injection drug user and alcohol misuse: Past injection drug use and alcohol misuse can have significant implications for the patient's health, including increased risk of infections, compromised immune function, and potential withdrawal symptoms. It is crucial for the nurse to be aware of these factors in order to provide appropriate care and support. Has productive cough severe enough to keep her awake: A severe productive cough that disrupts the patient's sleep suggests respiratory distress or possible worsening of the underlying condition. The nurse should assess the patient's respiratory status and implement interventions to alleviate the cough and improve rest.

Elevated temperature, pulse, and respiratory rate: An elevation in vital signs, including temperature, pulse, and respiratory rate, can indicate an infectious or inflammatory process. This warrants further assessment and intervention to manage the underlying condition. Diagnosis pneumonia: The diagnosis of pneumonia indicates a respiratory infection that requires close monitoring and appropriate treatment. The nurse should assess the patient's respiratory status, administer prescribed medications, and implement respiratory hygiene measures.

The following options are not immediate concerns or relevant assessment information:

Appointment the next day: While follow-up appointments are important, they do not require immediate attention upon receiving a hand-off report.

Marital status: Marital status is not typically an immediate concern for the nurse's assessment and care planning.

Daughter's name: The patient's family member's name is not an immediate concern or relevant assessment information for the nurse's immediate care.

Fever is present: While a fever is a symptom of an underlying condition, it is not the most critical concern.

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Correct Answer is B

Explanation

Rhinoplasty is a surgical procedure performed on the nose, and it often involves the placement of nasal packing to control bleeding, support the nasal structures, and promote healing. Nasal packing can cause mouth breathing and oral dryness, which can lead to increased swallowing as the patient tries to alleviate the discomfort.

While bleeding posterior to the nasal packing is a potential complication of rhinoplasty, it typically presents with other symptoms such as active bleeding, nasal discharge, or changes in vital signs. Without additional information or signs of active bleeding, it is less likely to be the cause of the patient's frequent swallowing in this scenario.

An adverse reaction to the analgesic is possible, but it would typically present with other symptoms such as allergic reactions (rash, swelling, difficulty breathing) or gastrointestinal symptoms (nausea, vomiting). In the absence of these symptoms, an adverse reaction to the analgesic is less likely.

Lastly, a normal response to the analgesic and surgery would not typically manifest as frequent swallowing. While pain medication can cause side effects, such as drowsiness or nausea, increased swallowing is not a common response.

A. The client has a fever. B. The patient requested that suctioning be performed. C. Crackles and wheezing is heard upon auscultation D. The tracheostomy dressing has a moderate amount of serosanguineous drainage. E. Suction was performed more than (4) hours ago.

Correct Answer is ["C","D","E"]

Explanation

Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.

The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.

Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.

While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.

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After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

Correct Answer is B

Explanation

Which condition or changes indicate to the nurse that a patient with a tracheostomy requires suctioning? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

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The nurse receives an order to draw a peak level on a patient prescribed Gentamicin via Intravenous (IV) infusion. When is the best time for the nurse to draw this peak level?

A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

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