A nurse is providing a change-of shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?
Client was nauseated immediately after surgery.
Client's pain relieved by position change.
Checked for peripheral IV blood return prior to antibiotic.
Client provided with breakfast tray at 0800.
The Correct Answer is B
A. Client was nauseated immediately after surgery: While postoperative nausea is important to document, it is an event that occurred in the past and may not reflect the client’s current status 36 hours after surgery.
B. Client’s pain relieved by position change: This information is critical as it reflects the current effectiveness of nonpharmacologic pain management strategies and guides ongoing care for comfort.
C. Checked for peripheral IV blood return prior to antibiotic: This is a routine nursing task that was completed. While important for safe medication administration, it's a procedural detail of a completed task and not usually included in a concise shift report.
D. Client provided with breakfast tray at 0800: Although documenting nutrition is important, the exact timing of meal delivery is less significant than clinical status information during shift handoff.
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Related Questions
Correct Answer is B
Explanation
A. Maintain bed elevation at 20°: The head of the bed should be elevated to at least 30° to 45° during enteral feedings to reduce the risk of aspiration. A 20° angle is inadequate for preventing reflux and potential aspiration.
B. Flush the tubing with 30 ml of water every 4 hr: Routine flushing of the feeding tube helps maintain patency and prevent clogging. Flushing every 4 hours is standard practice for continuous feedings to ensure uninterrupted delivery.
C. Place enough formula in the container to last 18 hr: Open system formula should be discarded after 4 hours to reduce the risk of bacterial contamination. Filling the container for 18 hours exceeds safe hang time recommendations.
D. Check for gastric residual every 12 hr: Gastric residuals should typically be checked every 4 to 6 hours for continuous feedings, or per facility policy. Waiting 12 hours may delay the identification of feeding intolerance or complications.
Correct Answer is ["A","B","C","D"]
Explanation
A. Explanation of the procedure: The provider must clearly describe the procedure, including what it involves, to ensure the client understands what they are consenting to. This supports informed decision-making.
B. Possible alternative treatments: Clients must be made aware of all reasonable alternatives to the proposed procedure, allowing them to choose the option that aligns best with their values and health goals.
C. Expected outcome of the procedure: Understanding the anticipated benefits and results helps the client weigh the risks and make an informed choice about whether to proceed with the surgery.
D. Potential complications: Full disclosure of potential risks and complications is a legal and ethical requirement. It ensures the client consents with a clear understanding of possible negative outcomes.
E. Cost of the procedure: While important, financial details are typically handled by administrative or billing staff, not the provider obtaining medical consent. It is not part of the informed consent content required from the medical team.
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