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 ["B","C","D","E"]

Explanation

The correct answers are Choices B, C, D, and E.

Choice A rationale: Refusal of meals, especially in an infected client, is not typically incident reportable. Nurses should note this in the client record and monitor the client's nutritional intake and overall condition.

Choice B rationale: Falls are always reportable incidents. When a client falls, an incident report is required to document the event, analyze contributing factors, and implement measures to prevent future falls.

Choice C rationale: Recording an approximate urine output due to leakage from the catheter bag is a reportable incident. Accurate measurement of urine output is essential, and an incident report helps to address the cause of leakage and prevent recurrence.

Choice D rationale: Administering antibiotics before blood culture and sensitivity testing can affect test results and is a reportable incident. The incident report documents the error and helps to implement measures to prevent such occurrences in the future.

Choice E rationale: Administering medication at the wrong time is a medication administration error. An incident report should be filed to document the deviation from the prescribed schedule and address any potential impacts on the client's condition.

A. A client who has a new diagnosis of diabetes mellitus and is awaiting teaching about meal planning. B. A client who has a urinary output of 30 mL in the past hour. C. A client who is postoperative following a hip arthroplasty and has a respiratory rate of 10/min. D. A client who is newly admitted and requires an admission assessment.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: This client has a new diagnosis and requires initial teaching about meal planning, which is typically a responsibility of a registered nurse (RN) due to the need for specialized knowledge and teaching skills.

Choice B rationale: This client has a low urinary output, which needs to be monitored, but the care required is within the scope of practice of a licensed practical nurse (LPN). They can manage and report findings to the RN.

Choice C rationale: This client has a low respiratory rate postoperatively, which could indicate respiratory depression. This requires immediate assessment and intervention from an RN, who can make complex clinical judgments and initiate appropriate care.

Choice D rationale: This client needs an admission assessment, which includes comprehensive initial evaluation. An RN is required for this as it involves detailed assessment, care planning, and initiation of care.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is B

Explanation

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