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

Answer and Explanation

The Correct Answer is D

The nurse should not include the client's frequency of call button use in the change-of-shift report. While this information might seem relevant, it can be misinterpreted and stigmatize the client. Sharing call button frequency without context could lead assumptions about the client being overly demanding or attention-seeking, instead of focusing on their potential needs and anxieties post-surgery.

Here's why the other options are acceptable to include:

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: Although the client is weaned, knowing their past ventilator settings provides valuable insight into their respiratory function and potential risks for decompensation.
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.

Therefore, the best answer is d. The frequency in which the client presses the call button.

Remember, a good change-of-shift report focuses on crucial clinical information relevant to the client's current condition and care plan, avoiding subjective observations that could lead to bias or misjudgment.

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Correct Answer is D

Explanation

Assign the client to a private room with negative air pressure.

Rationale:

A. Incorrect. Restricting fresh flowers from the client's room is not necessary for infection control purposes. However, some clients with pulmonary tuberculosis may have hypersensitivity reactions to certain plants or flowers, so the nurse should assess the client's allergies before allowing them in the room.
B. Incorrect. Maintaining a distance of 1.8 m (6 feet) from the client is not sufficient to prevent transmission of tuberculosis. Visitors should also wear a HEPA respirator and limit their contact time with the client.
C. Incorrect. A surgical mask is not adequate to protect the nurse from inhaling airborne droplet nuclei that contain Mycobacterium tuberculosis. The nurse should wear a high-efficiency particulate air (HEPA) respirator when providing client care.
D. Correct. Assigning the client to a private room with negative air pressure is the most effective way to prevent the spread of tuberculosis to other clients and staff members. The room should have at least six air exchanges per hour and an exhaust system that vents directly to the outside.

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?

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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?