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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Rotate staff members caring for the client: Consistency in caregivers helps build trust in clients with paranoid personality disorder. Frequent changes in staff can increase suspicion and worsen paranoia, making care more difficult.
B. Speak in a neutral tone when addressing the client: A neutral, calm, and non-threatening tone helps avoid triggering the client’s mistrust or defensiveness. Clear and straightforward communication is essential for maintaining therapeutic rapport.
C. Limit the clients opportunities to socialize with others: Social interaction, when appropriate and safe, can help reduce isolation. Restricting social opportunities without cause can reinforce paranoid ideation and hinder recovery.
D. Mix the medication with the client's food items: Covertly administering medication violates client autonomy and can intensify paranoia if discovered. Informed consent and transparent communication are essential in psychiatric care.

A. Mucus membranes B. Integumentary findings C. Emesis D. Behavior E. AST result F. Vital signs G. Movement of hands and fingers

Correct Answer is ["B","D","F"]

Explanation

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["B","D","F"]

Explanation

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