A nurse is providing change-of-shift report on a client who is postoperative following abdominal surgery. Which of the following statements should the nurse include in the change-of-shift report?

"The client's postoperative antibiotic was administered."

"The client's partner came to visit today."

"At 2200, the client's IV fluid bag and tubing will need replacing."

"Colonoscopy was performed 48 hours ago."

Answer and Explanation

The Correct Answer is C

A. "The client's postoperative antibiotic was administered." While this information is important, it is not typically included in the change-of-shift report unless there were specific issues related to antibiotic administration (e.g., allergic reactions, missed doses).
B. "The client's partner came to visit today." While this information might be relevant to the client’s social and emotional well-being, it is not critical for the shift report regarding clinical care.
C. "At 2200, the client's IV fluid bag and tubing will need replacing." This statement is important for continuity of care and should be included in the report to ensure that the next shift is aware of necessary actions.
D. "Colonoscopy was performed 48 hours ago." This information is relevant for understanding the client’s postoperative status but is less immediate compared to other details such as current medication administration or upcoming needs.

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Correct Answer is C

Explanation

A. Whole grain cereal: Not recommended. Whole grains can be high in insoluble fiber, which may worsen diarrhea.
B. Chocolate ice cream: Not recommended. Ice cream, especially chocolate-flavored, contains dairy and fat, which may exacerbate diarrhea.
C. Sliced bananas: Bananas are easy to digest, provide potassium, and can help firm up stools.
D. Hot coffee: Not recommended. Coffee is a stimulant and can irritate the gastrointestinal tract, potentially worsening diarrhea.

A. Postpone ADLS until an occupational therapist determines the client's abilities. B. Eliminate daily care that is not essential for the client's recovery. C. Inform the client of the time the ADLS will be performed. D. Determine the client's preferences.

Correct Answer is C

Explanation

A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.

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A nurse is providing change-of-shift report on a client who is postoperative following abdominal surgery. Which of the following statements should the nurse include in the change-of-shift report?

Nursing Test Bank

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