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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Contemplation: In the contemplation stage, individuals or groups are aware of a problem and are thinking about making a change but have not yet taken any action. The focus remains on weighing the pros and cons of changing behavior.
B. Action: The action stage involves actively modifying behaviors, environments, or systems. Since the group is already in the process of reducing pesticide use, they are implementing change, which aligns with the action phase of behavior change.
C. Maintenance: Maintenance is the stage in which individuals or groups work to sustain changes that have already been fully implemented. This group has not yet reached that point, as they are still actively working on the change.
D. Preparation: In the preparation stage, individuals or groups intend to take action soon and may begin making small changes. However, this does not fit the scenario because the group has moved beyond planning and is already enacting the change.
Correct Answer is D
Explanation
A. "Make sure you are holding your baby when your son comes to visit you in the hospital.”: While involving the older sibling can help with bonding, holding the newborn continuously may cause feelings of jealousy or exclusion in the 4-year-old child.
B. “Surprise your son with a new bedroom after you bring the baby home.”: Sudden changes like moving a child’s bedroom without preparation can increase anxiety and feelings of insecurity during a time of significant family adjustment.
C. “Use medical terminology when teaching your son about your new baby.”: Using complex medical terms may confuse a preschooler; age-appropriate language and simple explanations are more effective for understanding and comfort.
D. "Purchase a gift to give to your son from your baby.”: Providing a gift from the new baby helps the older child feel included, valued, and less jealous, fostering positive feelings about the sibling relationship and easing the transition.
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