A newly licensed nurse is giving a change-of-shift report using Introductions, Situation, Background, Assessment, Recommendation (ISBAR) to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the "Background" portion of the report?

A. "The client has a new prescription for incentive spirometry.": This statement is more appropriate for the "Assessment" or "Recommendation" section, as it pertains to current treatment plans and interventions rather than the background context of the client's history.

B. "The client's partner plans to return later today.": This information is relevant to the client's social support and engagement but is not critical background information. It may be included in the "Situation" or "Recommendation" sections instead.

C. "The client has no living family members.": This statement is pertinent to the "Background" portion, as it provides important context regarding the client's social situation and support system. Understanding the client's background helps the receiving nurse assess potential psychosocial needs and planning for care.

D. "I initiated a consultation by a nutritionist.": This action relates to ongoing care and assessment of the client's nutritional needs, making it more appropriate for the "Assessment" or "Recommendation" section. It is not part of the historical background needed for effective handoff.

A. Giving a glycerin suppository to a client for constipation: Medication administration, including rectal suppositories, requires assessment of bowel function, knowledge of contraindications, and evaluation of effectiveness, which fall under the responsibilities of a licensed nurse.

B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache: Assessing a client’s response to medication requires critical thinking, monitoring for adverse effects, and determining if additional interventions are needed, which are nursing responsibilities that cannot be assigned to assistive personnel.

C. Discussing dietary changes with a client who has a prescription for a gluten-free diet: Providing dietary education involves assessing the client’s current knowledge, identifying nutritional risks, and ensuring understanding of food choices, which requires professional nursing judgment or a consultation with a dietitian.

D. Measuring hourly urinary output for a client who is postoperative: Recording urinary output involves a simple measurement process that does not require clinical decision-making. Assistive personnel can accurately collect and document this data, allowing nurses to focus on interpretation and intervention if necessary.