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 B

Explanation

A. Identifying past coping skills is important but is not the priority in a crisis situation where the client's safety is at risk.
B. Ensuring the client’s immediate safety is the priority because they may still be in danger from the abusive partner. Crisis intervention focuses first on protecting the client from further harm.
C. Identifying support systems is beneficial for long-term recovery but does not take precedence over ensuring the client’s immediate safety.
D. Encouraging expression of feelings is therapeutic, but the priority is to remove the client from immediate harm before addressing emotional needs.

A. Remind the AP about maintaining client confidentiality. B. Notify the client of the breach of confidentiality. C. Notify the ethics committee of the breach of confidentiality. D. File an incident report with the risk management department.

Correct Answer is A

Explanation

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

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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

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Explanation

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Correct Answer is A

Explanation

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