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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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Placing soiled dressings in a biohazard trash receptacle is the appropriate practice for disposing of potentially infectious materials. It helps prevent the spread of microorganisms and ensures proper handling and disposal of contaminated items.
Clostridium difficile is a spore-forming bacterium that is not effectively killed by alcohol-based hand rubs. Hand hygiene for C. difficile requires the use of soap and water to thoroughly wash the hands.
Droplet precautions typically require the use of a surgical mask, not a gown and gloves. A gown and gloves are used for contact precautions.
The recommended bleach solution for blood spills is typically a 1:10 dilution, not 1:20. This concentration helps ensure effective disinfection and decontamination of the area.
Correct Answer is C
Explanation
Fluid overload refers to an excess volume of fluid in the body, which can occur as a result of various factors, including excessive fluid intake or inadequate fluid removal. Crackles heard in the lungs, also known as rales, can indicate fluid accumulation in the lungs, a condition known as pulmonary edema. It is a common manifestation of fluid overload and can be detected through auscultation of the lungs.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Decreased blood pressure is more commonly associated with hypovolemia or low blood volume, rather than fluid overload.
Decreased skin turgor is a sign of dehydration or reduced skin elasticity, which is typically seen in conditions involving fluid deficit rather than fluid overload.
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