A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?

Medical diagnosis.

Number of visitors.

Routine care.

Expected laboratory results.

Answer and Explanation

The Correct Answer is C

A bone scan that is scheduled for today. The nurse should include this information in the change-of-shift report because the oncoming nurse might have to modify the client’s care to accommodate leaving the unit.

Choice A is wrong because the client’s input and output for the shift are routine data that can be found in the client’s chart and do not need to be verbally reported.

Choice B is wrong because the client’s blood pressure from the previous day is not relevant to the current condition of the client and does not reflect any changes or interventions.

Choice D is wrong because the medication routine from the medication administration record is also routine data that can be accessed by the oncoming nurse and does not indicate any special needs or concerns.

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Correct Answer is A

Explanation

A. Frequent swallowing after a tonsillectomy may indicate postoperative bleeding. The nurse should check the back of the throat with a pen light to assess for signs of hemorrhage.
B. While obtaining vital signs is important, it does not directly address the concern of potential bleeding.
C. Administering analgesia is appropriate for pain management but does not address the priority concern of bleeding.
D. Offering water could potentially worsen bleeding if it is occurring and should not be the first action.

A. Place the client’s bed in the low position. B. Encourage the client to wear socks when ambulating. C. Position the client’s bedside table at the foot of the bed. D. Raise four side rails on the client’s bed.

Correct Answer is A

Explanation

This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.

Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.

Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.

Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.

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A nurse is preparing to give change-of-shift report to the oncoming nurse. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a preschooler immediately following a tonsillectomy and notices the child swallowing frequently. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?

Correct Answer is A

Explanation

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