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 C
Explanation
The correct answer is C. "Fidelity involves keeping promises made to clients." The rationale for this statement is that fidelity is a principle of ethics that requires nurses to be faithful, loyal, and trustworthy to their clients. Fidelity means that nurses should honor their commitments and obligations to their clients, such as following through with care plans, respecting confidentiality, and being honest. Fidelity also implies that nurses should advocate for their client's best interests and protect them from harm.
Correct Answer is C
Explanation
Choice A reason:
Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.
Choice B reason
Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.
Choice C reason:
Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.
Choice D reason:
Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.
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