A nurse is caring for a client who is pregnant.

Nurses' Notes 1000:

The client reports repeated episodes of vomiting and two episodes of diarrhea in past 24 hr. Client is at 18 weeks of gestation and reports a history of nausea and vomiting for the past 12 weeks.

1015:

IV fluids initiated. Prochlorperazine administered via intermittent IV bolus.

1100:

Client reports improvement in nausea. Ice chips provided. Client voided 50 mL of dark yellow urine.

The nurse is providing discharge teaching to the client.

For each discharge instruction, specify if each action is recommended or contraindicated for the client.

Choice A rationale:

This statement implies that the nurse attempted the dressing change but was unsuccessful. However, the information about the dressing not being soiled is irrelevant to the incident report. The key issue is the omission of the prescribed procedure.

Choice B rationale:

This statement acknowledges the omission but lacks specificity. It does not state the nature of the omission or the potential consequences, making it less informative for future prevention strategies.

Choice C rationale:

This statement clearly and concisely states the situation, indicating that the prescribed dressing change was omitted. It provides essential information for understanding what happened, allowing for appropriate investigation and preventive measures.

Choice D rationale:

This statement confirms the completion of the incident report but does not provide details about the incident itself. Without specific information about the omission, this statement is insufficient for understanding the nature of the error and implementing preventive actions.

A. The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.

B. The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.

C. The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.

D. The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.