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.”
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Attempt to extinguish the fire before evacuating clients: The priority is client safety. Attempting to extinguish a fire should only be done if the fire is small, contained, and the area has been cleared. Evacuation takes precedence over suppression efforts.
B. Aim the spray of the fire extinguisher at the top of the fire: The correct technique is to aim at the base of the fire to effectively cut off the fuel source. Aiming at the top will not extinguish the fire and may waste the extinguisher’s contents.
C. Open nearby doors and windows when the fire alarm sounds: Opening doors and windows can cause the fire to spread more rapidly by feeding it with oxygen. Doors should remain closed to help contain the fire and reduce the spread of smoke.
D. Have ambulatory clients walk independently to a safe location: Encouraging ambulatory clients to move independently helps prioritize assistance for those who are immobile or require more support. This approach ensures a quicker, safer evacuation process.
Correct Answer is ["A","B","C","E"]
Explanation
Rationale:
• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.
• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.
• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.
• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.
• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.
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