a nurse is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility which of the following informat a nurse is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility which of the following informat
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1. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?

Correct answer: D

Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.

2. Before administering blood products, which action should be taken?

Correct answer: A

Rationale: Before administering blood products, assessing the patient’s temperature is crucial. This action provides baseline data to detect any febrile reactions during or after the transfusion. Fever may indicate a transfusion reaction, so continuous monitoring of vital signs is essential throughout the procedure. Documenting the patient’s response (choice B) is important but comes after assessing the temperature. Priming IV tubing with 0.45% sodium chloride (choice C) is not directly related to the initial action required before administering blood products. Administering epinephrine (choice D) is not indicated unless there is a severe allergic reaction, which is not the standard initial step before blood product administration.

3. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

Correct answer: D

Rationale: In this scenario, offering pain medication to a postoperative client before ambulation is an example of beneficence. Beneficence is the ethical principle related to promoting the well-being of the client, which includes providing pain relief to improve the client's comfort and facilitate their recovery. Fidelity (choice A) is about honoring commitments and being faithful to agreements, not directly related to pain management. Autonomy (choice B) refers to respecting the client's right to make decisions about their care, not specifically about pain medication administration. Justice (choice C) involves fairness and equality in healthcare resource allocation, not directly applicable in this situation.

4. A breastfeeding mother complains of sore nipples. Which intervention should the nurse suggest?

Correct answer: B

Rationale: The correct intervention for sore nipples in a breastfeeding mother is to suggest applying lanolin cream after each feeding. Lanolin cream can help soothe and protect the nipples, promoting healing and reducing discomfort. Using a breast pump may not address the underlying issue causing soreness. Washing nipples with soap and water excessively can lead to dryness and further irritation. Reducing breastfeeding frequency may impact milk supply and bonding. Therefore, recommending lanolin cream is the most appropriate intervention to alleviate soreness in this situation.

5. What is the correct way to assess for pitting edema?

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

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