A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

"The client received morphine around lunch."

"The client had a lung biopsy 1 hour ago."

"Vital signs were obtained every 4 hours."

"The client's partner is at their bedside."

Answer and Explanation

The Correct Answer is B

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

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Correct Answer is C

Explanation

A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.

A. "I will make a note in your medical record that you don't understand the surgery." B. "I will tell your provider that you have questions about the surgery." C. "Would you like to hear about some other possible treatment options?" D. "Would you like me to tell you more about the procedure?"

Correct Answer is B

Explanation

A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.

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A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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