A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Rationale:

A. "The client can revoke consent even after the procedure has begun.": Clients have the legal right to withdraw consent at any time, including during a procedure. Respecting this autonomy is essential, and healthcare providers must stop the procedure if the client revokes consent.

B. "The nurse is responsible for obtaining informed consent.": Obtaining informed consent is the responsibility of the provider performing the procedure, who must ensure the client understands the risks, benefits, and alternatives. Nurses typically witness and verify the signature but do not obtain consent.

C. "Consent must be obtained from a family member if a client has a mental illness.": Consent depends on the client’s decision-making capacity, not solely on the presence of mental illness. If the client is competent, they can provide consent; if not, a legally authorized representative may be involved.

D. "The charge nurse will explain the risks of the procedure to the client.": Explaining procedure risks is the responsibility of the healthcare provider performing the procedure, not the charge nurse. This ensures that the explanation is accurate and comprehensive.

Rationale:

A. "The client in room 205 has had several visitors today." This is non-essential social information that does not contribute to continuity of care or clinical decision-making. Change-of-shift reports should focus on relevant clinical updates and care plans.

B. "The client in room 204 received some pain medicine earlier today." This statement lacks specificity, such as the type, dosage, time, and client response to the medication. Without detailed clinical context, the information is not useful for ensuring safe, consistent care.

C. "The client in room 205 is scheduled for a dressing change at 1800." This provides specific, actionable information that the oncoming nurse needs to know in order to follow the treatment plan and ensure timely wound care.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." This is essential procedural information that allows the next nurse to prepare the client appropriately and monitor for any pre-op needs, such as NPO status or lab work.

E. "The client in room 204 has a new prescription for IV gentamicin." This communicates a significant change in the client’s medication regimen, which may require monitoring for side effects, such as nephrotoxicity or ototoxicity, making it critical to include in report.