A nurse is preparing to give 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? (Select all that apply)

Preferred bath time.

Admission vital signs.

Time of last pain medication.

Steps required for dressing change.

Answer and Explanation

Correct Answer : C,D

The correct answers are C and D.

Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.

Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.

Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.

Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.

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Correct Answer is C

Explanation

Choice A rationale:

Enabling the airbag when the baby is in the front seat of the car is incorrect. Airbags can be dangerous for infants and young children, and it is recommended to keep them in the rear seat, preferably in a rear-facing car seat.

Choice B rationale:

Positioning the car seat's retainer clip at the level of the baby's belly button is incorrect. The retainer clip should be at armpit level to ensure proper positioning and safety.

Choice C rationale:

Keeping the baby rear-facing in the car seat until she is 2 years old is the correct understanding of car seat safety. This statement aligns with the American Academy of Pediatrics (AAP) recommendations, which suggest keeping infants rear-facing as long as possible, ideally until they reach the maximum height and weight limits of their car seat.

Choice D rationale:

Placing the baby in the car seat at a 90-degree angle is incorrect. The correct angle for a rear-facing car seat depends on the manufacturer's guidelines but typically ranges from 30 to 45 degrees. The 90-degree angle is not safe and can compromise the baby's airway.

A. Arms raised above her head with her legs elevated on pillows. B. Trendelenburg with her body in Sims' position. C. Prone with her arms at her side and her legs extended. D. Head flexed to the chest and her knees pulled up to the abdomen.

Correct Answer is D

Explanation

Choice A rationale:

Placing the client's arms raised above her head with her legs elevated on pillows (choice A) is not the correct position for a lumbar puncture. This position does not facilitate proper alignment of the spine and may hinder the procedure.

Choice B rationale:

The Trendelenburg position with the body in Sims' position (choice B) is not the correct position for a lumbar puncture. This position is not commonly used for lumbar punctures and may not provide the necessary anatomical alignment for a successful procedure.

Choice C rationale:

Placing the client prone with her arms at her side and her legs extended (choice C) is not the appropriate position for a lumbar puncture. This position does not allow for proper access to the lumbar region and may impede the procedure.

Choice D rationale:

The correct position for a lumbar puncture is to have the client flex their head to the chest and pull their knees up to the abdomen (choice D) This position maximizes the space between the lumbar vertebrae, making it easier for the provider to access the subarachnoid space for cerebrospinal fluid collection.

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A nurse is preparing to give 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? (Select all that apply)

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