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.
The Correct Answer is A
A. Medical diagnosis:
This provides context for the patient’s condition and guides the next nurse in understanding care priorities.
B. Number of visitors:
This is not essential clinical information for continuity of care.
C. Routine care:
Routine care (like scheduled hygiene or linen changes) is generally not included unless there was a deviation or issue.
D. Expected laboratory results:
Only actual or pending critical results should be reported. “Expected” values are not useful unless they have been received and are relevant.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Face the client at eye level when communicating.
This is because eye contact helps to establish rapport and trust with the client who has dementia and shows respect and attention. Facing the client at eye level also reduces distractions and background noise that might interfere with communication.
Choice B is wrong because offering correction of incorrect client statements can increase confusion, frustration, and agitation in the client who has dementia. Instead of correcting the client, the nurse should acknowledge their feelings and try to understand their perspective.
Choice C is wrong because reorienting the client to date and time with each encounter can be stressful and ineffective for the client who has dementia. Reorientation may work in the early stages of dementia, but as the disease progresses, the client may lose their ability to retain new information and may become more disoriented. Instead of reorienting the client, the nurse should use orienting names or labels whenever possible, such as “Your son, Jack” .
Choice D is wrong because avoiding using gestures when communicating with the client who has dementia can limit the nurse’s ability to convey meaning and emotion. Gestures can help to supplement verbal communication and provide cues for the client who has difficulty understanding words. However, the nurse should avoid using gestures that might be misinterpreted or threatening to the client, such as pointing or waving .
Correct Answer is A
Explanation
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
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