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."

Answer and Explanation

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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Correct Answer is A

Explanation

A. Contacting the case manager is crucial to explore various discharge options and ensure the client's needs are met appropriately.
B. Recommending long-term care should be considered after exploring other options and assessing the client's specific needs.
C. Requesting assistance from another family member is a potential option but should be explored in conjunction with other solutions.
D. Delaying discharge might not address the partner's inability to provide care and doesn't explore alternative solutions.

A. Keep the four side rails up on beds at night. B. Institute rounds every 2 hr during the day to offer toileting C. Accompany residents older than 85 years of age during ambulation D. Apply vest restraints on residents who are confused. E. Apply vest restraints on residents who are confused.

Correct Answer is B

Explanation

A. Keeping all four side rails up on beds can increase the risk of entrapment or injury and isn't recommended as a fall prevention strategy.
B. Instituting regular rounds during the day to offer toileting helps prevent falls related to residents attempting to get to the bathroom independently.
C. Accompanying older residents during ambulation is helpful but might not be feasible at all times and for all residents.
D. Using vest restraints can lead to physical and psychological complications and is not recommended due to ethical and safety concerns.

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