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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. The client’s date of birth.
Choice A reason: The client’s date of birth is a critical identifier in healthcare settings. It is unique to the individual and does not change, making it a reliable way to confirm a patient’s identity. This is especially important in acute care settings where accurate patient identification is crucial for safe medication administration. Using the date of birth along with another identifier, such as the patient’s name, aligns with the best practices for patient safety.
Choice B reason: While a client’s full medical diagnosis is important information for a nurse to know, it is not used as an identifier for medication administration. The diagnosis helps inform treatment decisions and care planning but does not uniquely identify a patient. Multiple patients could have the same diagnosis, which could lead to medication errors if used as an identifier.
Choice C reason: A client’s telephone number is not a standard identifier used in healthcare settings for medication administration. Telephone numbers can change and are not unique to an individual. They also do not provide immediate verification of a patient’s identity at the bedside.
Choice D reason: The room number of the client is not a primary identifier for patient identification in medication administration. Room numbers are not unique to individuals and can change if a patient is moved. It is possible for errors to occur if room numbers are used as the sole identifier, as another patient could be in that room at a different time.
Correct Answer is C
Explanation
Choice A rationale:
Offering toileting opportunities every 1 to 2 hours is a valid intervention in a bladder training program. However, it should not be the first action. Before establishing a toileting schedule, the nurse should assess the client's current voiding patterns to determine the most appropriate schedule based on the client's needs.
Choice B rationale:
Assisting the client with relaxation techniques can be beneficial in managing urinary incontinence or frequency, but it should not be the first action. Understanding the client's voiding pattern and any factors contributing to their urinary issues is essential before implementing relaxation techniques.
Choice C rationale:
Determining the client's pattern for voiding is the first step in developing a tailored bladder training program. This assessment helps identify the client's specific needs and enables the nurse to create a personalized plan that addresses their issues effectively.
Choice D rationale:
Discouraging intake of carbonated beverages is a valid intervention in managing urinary incontinence or frequency, but it should not be the first action. It's important to assess the client's individual habits and patterns before making dietary recommendations.
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