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 A
Explanation
Rationale:
A. 300 mg PO od: The dose is written clearly with no trailing zeros, and “od” (once daily) is acceptable though “daily” is preferred for clarity. This entry minimizes risk of misinterpretation and decimal errors.
B. 3.0 mg PO gd: Using a trailing zero (3.0 mg) increases the risk of a tenfold dosing error if the decimal point is missed. Also, “gd” is an incorrect abbreviation; “daily” or “once daily” should be used.
C. 10.000 units IV dally: Writing “10.000” with multiple trailing zeros is dangerous because the decimal point might be overlooked, causing a ten-thousand-fold error. Also, “dally” is a misspelling of “daily.”
D. 05 mL IM daily: Leading zeros before whole numbers (05 mL) are unnecessary and can cause confusion. The correct notation is “5 mL.” Leading zeros should only be used before decimals less than one (e.g., 0.5 mL).
Correct Answer is C
Explanation
Rationale:
A. “I will wait 15 minutes before taking a second tablet.": Waiting 15 minutes delays relief and increases the risk of complications. The client should take a second tablet if chest pain is unrelieved after 5 minutes, up to three doses within 15 minutes, then seek emergency help if symptoms persist.
B. "I should stop taking the medication if I get a headache.": Stopping the medication due to a headache overlooks the therapeutic benefit. Headaches are a common side effect caused by vasodilation and can be managed with mild analgesics while continuing the medication as prescribed.
C. "I should expect pain relief in 1 to 3 minutes.": Sublingual nitroglycerin is rapidly absorbed through the oral mucosa, leading to relief typically within 1 to 3 minutes. This fast onset is essential for treating acute angina episodes effectively.
D. "I will swallow the tablet for faster absorption.": Swallowing the tablet bypasses the sublingual route, delaying its effect due to first-pass metabolism in the liver. The tablet must be placed under the tongue to ensure rapid absorption and therapeutic effectiveness.
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