A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?
"The client is the president of a local bank,"
"The client's partner came to visit him 2 hours ago."
"The client has routine vital signs prescribed."
"The client is in the radiology department for a chest x-ray."
The Correct Answer is D
A. Mentioning that the client is the president of a local bank might not be pertinent to the client's current health status or care needs and is not typically included in a change-of- shift report unless relevant to the care plan.
B. The fact that the client's partner came to visit two hours ago might be important for emotional support or social interaction but might not be crucial information for the oncoming nurse unless relevant to the client's condition.
C. The client has routine vital signs prescribed” is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
D. This is critical information for the incoming nurse. It informs them that the client is currently away from the unit, which may affect the plan of care, including monitoring, medication administration, or any interventions needed during the client’s absence. It is important for the incoming nurse to be aware of the client's current status and whereabouts.
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Related Questions
Correct Answer is C
Explanation
A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
Correct Answer is A
Explanation
A. Placing the client's ring in the facility safe ensures that it is securely stored and prevents loss or misplacement, which is standard procedure for valuable personal items before surgery.
B. Placing the ring in the bag with the client’s clothing is not secure, as it increases the risk of loss or theft.
C. Taping the ring to the client’s finger is not ideal because jewelry should generally be removed before surgery to prevent complications such as swelling, circulation issues, or electrical burns from cautery equipment.
D. Keeping the ring for the client is inappropriate because staff should not personally hold onto a client’s valuables. Instead, valuables should be properly documented and stored per facility policy.
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