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's partner visited earlier today for 2 hours."

"The client received the prescribed antibiotic every 8 hours."

"The client's mother died 4 years ago from breast cancer."

"The client reports pain is reduced when he is positioned on his side.”

Answer and Explanation

The Correct Answer is D

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Rationale:

• "Use sunglasses if your eyes are sensitive to light." Exophthalmos from Graves' disease can persist even after thyroidectomy. Sunglasses help reduce photophobia and protect protruding eyes from dryness and injury.

• "Continue eating foods with protein." Protein is essential for wound healing and energy. Postoperative hypermetabolic states can also increase protein needs, so adequate intake supports recovery.

• "You need to support your neck when coughing or moving." Neck support prevents strain on the surgical site and reduces the risk of wound dehiscence or hematoma formation during activities that increase intrathoracic pressure.

• "Remain on bedrest for 3 to 5 days following discharge." Prolonged bedrest is not recommended post-thyroidectomy. Early ambulation reduces risk of complications such as pneumonia and deep vein thrombosis and supports normal recovery.

• "You will no longer need to take any medications for your thyroid now that you have had surgery." Total or subtotal thyroidectomy often results in hypothyroidism, requiring lifelong thyroid hormone replacement (e.g., levothyroxine). Medication needs depend on the amount of thyroid tissue removed.

A. Administer haloperidol via the intramuscular route. B. Collect data regarding the client's feelings. C. Obtain assistance to apply wrist restraints. D. Move the client into the seclusion room.

Correct Answer is B

Explanation

Rationale:

A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.

B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.

C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.

D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

A nurse on a postpartum unit is receiving change-of-shift report for 4 clients. Which of the following clients should the nurse plan to see first?

A nurse is reinforcing discharge teaching about postpartum activity restrictions to a client who had a cesarean birth 2 days ago. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is preparing to administer eye drops to a child. Which of the following actions should the nurse take?

A nurse is reinforcing teaching about foods that are high in folic acid with a client who is at 8 weeks of gestation. Which of the following foods should the nurse recommend as the best source of folic acid?

A nurse is receiving a telephone prescription from a client's provider. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is reinforcing teaching with a client who has a new prescription for propranolol. The nurse should include which of the following as a potential adverse effect of this medication?