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 received the prescribed antibiotic every 8 hours."
"The client's mother died 4 years ago from breast cancer."
"The client's partner visited earlier today for 2 hours."
The Correct Answer is A
A. Correct. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.
B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.
C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.
D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.
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Related Questions
Correct Answer is C
Explanation
A. Assisting the client to the bathroom at regular intervals helps prevent falls due to toileting needs.
B. Locking the wheels on the bed prevents unwanted movement and reduces the risk of falls when the client is in bed.
C. Raising all four side rails is considered a restraint, which can increase the risk of falls or injury if the client tries to climb over them. Restraints should be avoided unless absolutely necessary and prescribed by a healthcare provider. In most cases, raising two side rails is sufficient to prevent the client from accidentally rolling out of bed while allowing them to safely exit the bed.
D. Clearing the path from obstacles and furniture reduces the risk of falls by providing a safe and unobstructed route to the bathroom.
Correct Answer is C
Explanation
A. Discarding worksheets containing client information in a wastebasket does not ensure proper disposal of confidential information and could compromise confidentiality.
B. Writing a client's diagnosis on the message board in the client's room could breach confidentiality, as it could potentially be seen by unauthorized individuals.
C. This action protects client confidentiality because it involves discussing sensitive information in a private setting where unauthorized individuals are less likely to overhear. This is an appropriate method of communicating client information during a handoff.
D. While sharing relevant information with personnel directly involved in the client's care is generally acceptable, it must still be done in a manner that safeguards confidentiality.
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