8-year-old male admitted with cystic fibrosis reports the following symptoms:

• Shortness of breath
• Wheezing throughout lung fields
• Productive cough with thick sputum

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?

• Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:

  c. The time of the client's last dose of pain medication

  Here's why:

• a. The frequency in which the client presses the call button:While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
• b. The client's most recent ventilator settings:Since the client is already weaned from ventilation, this information is no longer pertinent.
• d. The last time the provider evaluated the client:While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
• c. The time of the client's last dose of pain medication:Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.

• Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.

"How does this make you feel?"

• A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
• B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
• C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
• D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.