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."
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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Related Questions
Correct Answer is B
Explanation
Before any invasive procedure, it is essential to ensure that the client has given informed consent. Informed consent involves providing the client with detailed information about the procedure, its risks and benefits, and alternatives. The client should have the opportunity to ask questions and fully understand the procedure before giving consent.
Oral contrast solutions are typically used for imaging procedures such as CT scans or X-rays, not for esophagogastroduodenoscopy. This procedure involves the insertion of a flexible tube with a camera into the esophagus, stomach, and duodenum to visualize the upper gastrointestinal tract.
While it is important to provide the client with information about the duration of the procedure, stating a specific time frame may not be accurate or helpful. The duration of an esophagogastroduodenoscopy can vary depending on factors such as the complexity of the procedure and the client's individual circumstances.
Having a full bladder is not necessary for an esophagogastroduodenoscopy procedure. This requirement may be relevant for other procedures, such as pelvic ultrasound, but it is not applicable in this case.
Correct Answer is A
Explanation
Understanding the client's current voiding pattern is essential in developing an effective bladder training program. By determining the client's pattern for voiding, the nurse can identify any irregularities, frequency, and specific times when the client is more likely to void. This information will serve as a baseline for developing an individualized bladder training program.
B. Offering toileting opportunities every 1 to 2 hours is an appropriate intervention to ensure regular and scheduled voiding. However, before implementing this intervention, it is necessary to determine the client's current voiding pattern to identify any existing irregularities or potential areas of improvement.
C. Assisting the client with relaxation techniques can help promote effective voiding and reduce anxiety or stress related to the act of voiding. However, this intervention can be more effective once the nurse has assessed the client's voiding pattern and identified specific areas where relaxation techniques can be beneficial.
D. Discouraging the intake of carbonated beverages is a valid intervention as carbonated beverages can irritate the bladder and contribute to increased frequency and urgency of urination.
However, this intervention can be implemented as part of a comprehensive bladder training program after the nurse has assessed the client's current voiding pattern and developed an individualized plan.
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