A nurse is providing a change-of-shift report for a client. Which of the following information should the nurse include in the report?

"The client's partner visited earlier today for 2 hours."

"The client received the prescribed antibiotic every 8 hours."

"The client reports pain is reduced when he is positioned on his side."

"The client's mother died 4 years ago from breast cancer."

Answer and Explanation

Correct Answer : B,C

The client received the prescribed antibiotic every 8 hours: This is important information as it relates to the client's medication administration and treatment plan. It allows the incoming nurse to be aware of the medication schedule and ensure continuity of care.

The client reports pain is reduced when positioned on his side: This is significant information as it informs the incoming nurse about the client's preferred position for pain management. It helps guide the nurse in providing comfort measures and appropriate positioning for the client.

The client's mother died 4 years ago from breast cancer: This information may not be considered vital for the change-of-shift report unless it directly impacts the client's current condition or ongoing care.

While it's important to document visitors and support persons, this information may not be considered crucial for the change-of-shift report unless it directly impacts the client's care or well-being.

In summary, the nurse should include information that is pertinent to the client's immediate care needs and current condition. This includes medication administration, pain management preferences, changes in condition, or any relevant information that may impact the client's care plan.

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Correct Answer is C

Explanation

A.If the client is independent, give them privacy to bathe, if they prefer. If leaving a client unattended, check on them every 5 minutes or more frequently as needed. Ensure the client knows how to use safety items such as shower chairs and grab bars.

B.Adding bath oil can make the tub slippery and increase the risk of falls. If used, it should be added before the client gets in, and the client should be made aware so they can be cautious.

C.Draining the tub water before the client gets out helps prevent slips and falls that can occur if the client attempts to exit the tub while the water is still present. This practice enhances safety by reducing the risk of accidents.

D.Tub baths or very warm showers can lead to a person feeling faint, nauseous, or tired. Baths should not last longer than 20 minutes and should be discontinued at the first sign of patient discomfort, weakness, or complaints of feeling faint.

A. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. B. A nurse discovers that a client's family member has administered a PCA dose. C. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. D. A nurse observes a client vomiting after receiving an oral pain medication.

Correct Answer is A

Explanation

An incident report is a tool used to document any unexpected or adverse event that occurs in the healthcare setting. It is important to report incidents to ensure proper investigation, analysis, and implementation of measures to prevent future occurrences.
In this example, the incident involves an error with an electronic IV pump resulting in the delivery of an incorrect amount of fluid, which can have serious implications for the client's safety and well-being.
The other examples listed may require further actions but may not necessarily require an incident report:
B. A nurse discovers that a client's family member has administered a PCA dose: While it is concerning that a client's family member administered a patient-controlled analgesia (PCA) dose, it is more appropriate to address this situation through immediate intervention, education, and communication with the healthcare provider. An incident report may not be necessary unless there are further complications or system issues related to this incident.
C. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm: While the observation of improper restraint removal raises concerns about proper restraint protocol, it is more appropriate to address this situation through immediate intervention and communication with the involved nurse and healthcare provider. Depending on the severity of the situation, an incident report may or may not be warranted, but it is not the primary action in this case.
D. A nurse observes a client vomiting after receiving an oral pain medication: While it is important to assess and address the client's condition and any adverse reactions, such as vomiting after receiving medication, it may not necessarily require an incident report. The nurse should assess the client, notify the healthcare provider, and document the incident appropriately in the client's medical record.

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A nurse is providing a change-of-shift report for a client. Which of the following information should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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