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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Correct Answer is B
Explanation
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.
Correct Answer is A
Explanation
A. Review the child's electronic pain diary: This should be the first action as it provides valuable information about the frequency, triggers, duration, and severity of the headaches. It helps the nurse and provider make informed decisions about treatment and next steps.
B. Request a change in medication from the provider: Medication changes should be based on a thorough assessment of the child’s headache pattern and response to current therapy, which starts with reviewing documented data.
C. Set up an appointment with the school nurse: While coordination with the school is important for managing chronic conditions, it is not the priority action before understanding the nature and pattern of the headaches.
D. Refer the family to a chronic pain support group: Support groups are helpful in long-term management, but should follow a thorough assessment and diagnosis of the child’s condition and needs.
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