A nurse is preparing to give a change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report?
Steps required for dressing change
Admission vital signs
Preferred bath time
Time of last pain medication
The Correct Answer is D
The correct answer is D.
Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.
The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.
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Related Questions
Correct Answer is D
Explanation
The correct answer is D. Limiting the number of choices for the client who has Alzheimer's disease can help reduce confusion and frustration and promote independence and dignity. Using written signs to assist the client with locating the bathroom may not be helpful, as the client may have difficulty reading or remembering what they mean. Using confrontation to manage the client's behavior can increase agitation and aggression and worsen cognitive decline. Providing a stimulating environment for the client can also overwhelm and overstimulate them and cause sensory overload.
Correct Answer is D
Explanation
The correct answer is choice D. Document the client’s condition after every 15 minutes.
Choice A rationale:
Requesting a PRN restraint prescription for clients who are aggressive is not appropriate because restraints should only be used as a last resort and not on a PRN basis. Restraints should be used only when necessary to ensure the safety of the patient and others, and always with a specific, time-limited order.
Choice B rationale:
Removing the client’s restraint every 4 hours is not frequent enough. Restraints should be removed more frequently to assess the patient’s condition, provide care, and ensure that the restraint is still necessary.
Choice C rationale:
Attaching the restraint to the bed’s side rails is unsafe. Restraints should be attached to a part of the bed frame that moves with the patient to prevent injury.
Choice D rationale:
Documenting the client’s condition every 15 minutes is the correct guideline. Frequent documentation ensures that the patient’s condition is continuously monitored, and any changes can be addressed promptly to ensure safety and well-being.
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