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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reviewing facility policies is important but might not immediately address the reasons why the nurses are not taking breaks.
B. Discussing time management strategies might be helpful, but it's crucial to first understand the reasons behind the nurses' behavior.
C. Providing coverage for the nurses' breaks might be a short-term solution but doesn't address the underlying reasons for not taking breaks.
D. Determining the reasons the nurses are not taking scheduled breaks is the initial step to understand if it's due to workload, personal choice, or other factors. This information can guide appropriate interventions or support for the nurses.
Correct Answer is D
Explanation
Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.
Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.
Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.
Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.
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