A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy.

Which of the following information should the nurse not include in the change-of-shift report?

The last time the provider evaluated the client

The client's most recent ventilator settings

The time of the client's last dose of pain medication

The frequency in which the client presses the call button

None

Answer and Explanation

The Correct Answer is C

a. The last time the provider evaluated the client: This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
b. The client's most recent ventilator settings: The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
c. The time of the client's last dose of pain medication: This helps manage the client's pain effectively and prevent potential withdrawal symptoms.

d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.

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Correct Answer is D

Explanation

Verify the client and blood product information with another licensed nurse.

Rationale:

A - This is not a correct procedure for client identification, but rather for blood compatibility. The nurse should check the client's blood type and crossmatch it against the blood product label, not the provider's orders.
B - This is not a reliable method of client identification, as the client may not know or remember their blood type correctly. The nurse should use two identifiers, such as name and date of birth, to confirm the client's identity.
C - This is not a relevant step for client identification, but rather for informed consent. The nurse should ensure that the client has signed an informed consent form before administering blood, but this does not verify that the blood product matches the client.
D - This is the correct procedure for client identification, as it involves two licensed nurses who independently check and confirm the client's identity and the blood product information, such as blood type, Rh factor, expiration date, and serial number.

A. "I'm sure your family does not want you to die." B. "Why would you believe such things?" C. "How does this make you feel?" D. "You should talk to your family about your feelings."

Correct Answer is C

Explanation

"How does this make you feel?"

A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.

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A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse not include in the change-of-shift report?

Nursing Test Bank

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A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy.

Which of the following information should the nurse not include in the change-of-shift report?