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 B
Explanation
Rationale:
A. Dilated pupils: Hydromorphone, an opioid, typically causes pupil constriction (miosis), not dilation. Dilated pupils may occur in opioid overdose only as a sign of severe hypoxia, but are not a common adverse effect of appropriate therapeutic dosing.
B. Urinary retention: Urinary retention is a known adverse effect of opioids like hydromorphone. Opioids can impair bladder muscle tone and suppress the urge to void by affecting central and peripheral nervous system pathways.
C. Hypertension: Hydromorphone generally causes hypotension due to vasodilation and histamine release. Hypertension is not a typical response and would more likely suggest untreated pain or another underlying condition.
D. Tachypnea: Opioids depress the respiratory center in the brain, which can lead to bradypnea rather than tachypnea. An increase in respiratory rate is not characteristic of opioid use unless it’s a response to severe, unmanaged pain.
Correct Answer is A
Explanation
Rationale:
A. Place a towel in the sink when cleaning the dentures: Lining the sink with a towel or filling it partially with water provides a cushion to prevent the dentures from breaking if accidentally dropped during cleaning. This is a key safety step in proper denture care.
B. Remove the lower dentures before the upper dentures: Upper dentures should be removed first because they are usually looser and easier to dislodge. Removing the lower dentures first increases the risk of damaging the upper set or causing discomfort to the client.
C. Store the dentures in a dry denture cup on the bedside table after cleaning: Dentures should always be stored in water or a denture-cleaning solution when not in use to prevent warping. Leaving them dry can cause them to crack, lose their shape and may increase contamination risk.
D. Use a circular motion to cleanse the biting surface of the dentures: Denture cleaning requires gentle scrubbing using vertical or back-and-forth strokes rather than circular motions, to effectively remove debris and avoid damaging the prosthetic structure.
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