A nurse is preparing to provide a change-of-shift report. Which of the following information should the nurse include in the report?
"Client in room 303 is requesting snacks between meals."
"Client in room 304 has a laptop that they use for relaxation."
"Client in room 302 has multiple visitors."
"Client in room 301 is in the cardiac catheterization lab."
The Correct Answer is D
Rationale:
A. "Client in room 303 is requesting snacks between meals.": While client preferences are important, this information is non-urgent and can be communicated through care plans or written notes. It does not directly impact immediate nursing care during a shift change.
B. "Client in room 304 has a laptop that they use for relaxation.": This is personal, non-clinical information and is not essential for safe and effective handoff communication. Shift reports should focus on medical status, treatment plans, or immediate needs.
C. "Client in room 302 has multiple visitors.": Visitor status is not a priority item in a shift report unless it directly affects client care, safety, or monitoring. Including such information can distract from more clinically significant updates.
D. "Client in room 301 is in the cardiac catheterization lab.": This is critical information because it reflects a current procedure, potential risks, and possible post-procedure care needs. Reporting this ensures continuity of monitoring and prioritization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.
B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.
C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.
D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.
Correct Answer is D
Explanation
Rationale:
A. Bleeding time: This test evaluates platelet function and capillary integrity, not anticoagulation status. It is not used to monitor warfarin therapy.
B. aPTT: Activated partial thromboplastin time is used to monitor heparin therapy, not warfarin. Warfarin affects different clotting factors primarily measured by PT/INR.
C. Factor VIII: This assesses clotting factor levels, particularly relevant in hemophilia A. It does not provide information about warfarin’s anticoagulant effects.
D. INR: The International Normalized Ratio is the standard test used to monitor warfarin therapy. It adjusts for variability in PT results and determines if warfarin is in the therapeutic range.
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