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

"The client's partner visited earlier today for 2 hours."

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

Answer and Explanation

The Correct Answer is A

This statement should be included in the change-of-shift report because it provides vital information about the patient’s condition and any changes that have occurred to the patient during the shift.

Statement B is wrong because it does not provide relevant information about the patient’s current condition or changes that have occurred during the shift. Statement C is wrong because it does not provide relevant information about the patient’s medical condition. Statement D is wrong because it does not provide new information about changes that have occurred during the shift.

Change-of-shift reports are key to inpatient care because they provide vital information about and responsibility for the patient from the off-going provider to the on-coming provider.

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Correct Answer is A

Explanation

Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.

Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.

Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.

Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.

A. Verify the medication three times with the medication administration record. B. Document medication administration prior to administering medication. C. Administer time-critical medication 60 min before or after the scheduled time. D. Identify the client by using one identifier before giving the medication.

Correct Answer is A

Explanation

a. Verify the medication three times with the medication administration record.

When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.

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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

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Correct Answer is A

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