A nurse is providing change of shift report for a client. Which of the following information should the nurse include in the report?
"The client reports pain is reduced when he is positioned on his side."
"The client received the prescribed antibiotic every 8 hours."
"The client's mother died 4 years ago from breast cancer."
"The client's partner visited earlier today for 2 hours."
The Correct Answer is A
A. Correct. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.
B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.
C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.
D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement shows that the client understands the importance of monitoring the color of the stoma and seeking medical attention if any concerning changes occur. A purple or dark discoloration of the stoma can indicate inadequate blood supply to the area, which requires immediate medical evaluation.
"I will irrigate the colostomy every day." Colostomy irrigation is not typically done every day. It is a procedure used for some individuals with specific types of colostomies to establish a regular bowel movement pattern. The frequency and need for colostomy irrigation should be discussed and determined with the healthcare provider.
"I should expect my stool to be formed." Depending on the location and type of colostomy, the consistency of stool can vary. In the case of an ascending colostomy, the stool is usually liquid or semi-liquid because it is closer to the beginning of the large intestine. Expecting formed stool with an ascending colostomy would not be accurate.
"I will no longer be able to eat nuts." The ability to eat nuts or any other specific foods will depend on individual tolerance and the advice of a healthcare provider. In general, having a colostomy does not mean that all foods need to be eliminated from the diet. A well-balanced and varied diet can still be maintained with appropriate consideration for individual preferences and any dietary restrictions based on the specific situation.
Correct Answer is D
Explanation
The correct answer is choiced. "Soiled dressings should be placed in a biohazard trash receptacle.".
Choice A rationale:
For a client who has Clostridium difficile, hand hygiene should be performed with soap and water, not an alcohol-based rub, as alcohol does not effectively kill C. difficile spores.
Choice B rationale:
Droplet precautions typically require wearing a mask, not necessarily a gown and gloves. Gown and gloves are more commonly associated with contact precautions.
Choice C rationale:
Following a blood spill, a bleach solution with a ratio of 1 to 10 is recommended, not 1 to 20. This higher concentration ensures effective disinfection.
Choice D rationale:
Placing soiled dressings in a biohazard trash receptacle is correct. This prevents the spread of infection and ensures proper disposal of contaminated materials.
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