The nurse is giving report at the end of a shift to the incoming nurse at 1900. A client was admitted with pneumonia that morning. Which information is most important for the nurse to communicate about the client during the change-of-shift report (hand-off)?
a. Chest x-ray showed left lobe infiltrate and white blood cell count of 14,000/mm3
b. Client's spouse was rude to the nurse earlier
c. Current respirations are 24/min; pulse oximetry is 93% on 2 L/min
d. Intravenous (IV) line has been infusing without complications
Ans: c. Current respirations are 24/min; pulse oximetry is 93% on 2 L/min
You might also like to view...
A pregnant woman who thinks she is in labor asks the nurse how they will determine whether her membranes have ruptured. Which statement by the nurse is correct?
a. "Nitrazine paper will turn blue in the presence of amniotic fluid." b. "Amniotic fluid is yellow and has a different consistency than urine." c. "Litmus paper will turn blue in the presence of amniotic fluid." d. "Amniotic fluid has a distinct odor that we will assess."
List seven sites where pressure ulcers commonly develop.
What will be an ideal response?
Which of the following is a true statement regarding hearing loss?
A) Otosclerosis is the most common cause of hearing loss. B) Loud noise does not cause hearing loss. C) Tinnitus is ringing in the ears. D) It affects about 90% of people over 60 years of age.
A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?
a. Blood pressure readings are taken in both the arms and the thighs. b. The patient is assisted to a lying position, and his blood pressure is taken. c. His blood pressure is recorded in the lying, sitting, and standing positions. d. His blood pressure is recorded in the lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.