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 include in the change-of-shift report?
The frequency in which the client presses the call button
The client's most recent ventilator settings
The time of the client's last dose of pain medication
The last time the provider evaluated the client
The Correct Answer is C
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Out of the provided options, the most important information for the nurse to include in the change-of-shift report is:
c. The time of the client's last dose of pain medication
Here's why:
- a. The frequency in which the client presses the call button: While this could be relevant to assess the client's overall well-being or potential anxiety, it's not as crucial as pain management in this specific scenario.
- b. The client's most recent ventilator settings: Since the client is already weaned from ventilation, this information is no longer pertinent.
- d. The last time the provider evaluated the client: While provider updates are important, especially after major procedures like a pneumonectomy, knowing the exact timing isn't as critical as pain management, especially considering the potential for increased pain after surgery and weaning from ventilation.
- c. The time of the client's last dose of pain medication: Pain management is paramount after a pneumonectomy. Knowing the timing of the last dose allows the receiving nurse to assess the need for further medication and potential for breakthrough pain management. Additionally, it provides a baseline for monitoring pain trends and potential complications related to pain, such as decreased mobility or respiratory compromise.
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Therefore, while all the information listed could be relevant at some point, knowing the time of the last pain medication dose is the most crucial for immediate patient care and should be prioritized in the change-of-shift report for a post-pneumonectomy client transitioning from ICU to the medical floor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Taking corrective measures to enforce hand hygiene should not be the first step. It is important to establish a baseline and understand the current situation through data collection and analysis before implementing corrective measures.
Choice B rationale:
Establishing methods for collecting data within the facility is a crucial first step. Gathering information about the current hand hygiene practices, compliance rates, and areas of improvement is essential for the audit process. Data collection provides a factual basis for identifying problems and implementing targeted interventions.
Choice C rationale:
Comparing the facility's data with the established criteria for hand hygiene is a subsequent step after data collection. This step helps in evaluating the current practices against the accepted standards and guidelines. However, it is not the first step in the audit process.
Choice D rationale:
Determining the accepted standards for hand hygiene is an essential first step. It involves researching and understanding the national and international guidelines, protocols, and recommendations related to hand hygiene. Knowing the standards helps the task force establish a benchmark against which the facility's practices can be evaluated. It provides a foundation for data collection and subsequent analysis.
Correct Answer is A
Explanation
- A is correct because facilitating an interdisciplinary conference at the new facility for the family can help address their concerns, provide information about the client's plan of care, and promote continuity of care.
- B is incorrect because referring the client and family to a social worker for assistance and a follow-up meeting is not enough to address their immediate concerns and does not involve other members of the health care team.
- C is incorrect because reassuring the client's family that the same provider will provide care at the new facility may not be true and does not address their specific concerns about the level of care.
- D is incorrect because telling the family that the rehabilitation facility has an excellent client care record is not enough to address their specific concerns and may sound dismissive.
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