A nurse working in a long-term care facility is giving change-of-shift report on a client who had a stroke. Which of the following information should the nurse include in the report?

The client's blood pressure was recorded at 0730 and 1130.

The client's pain medication was administered twice during this shift.

The client's enteral feeding bag needs to be changed at 2200.

The client received a bath and backrub.

Answer and Explanation

The Correct Answer is A

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

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Correct Answer is B

Explanation

A. Completing an incident report is an important step to document the error, but the immediate priority is to assess the client's condition and address any potential adverse effects. Incident reporting can follow once the immediate assessment and interventions are completed.

B. Checking the client's vital signs is the first action to take. The nurse needs to assess the client's physiological response to the double dose, as some medications can have significant effects on vital signs. Monitoring vital signs provides crucial information to determine the client's stability and whether additional interventions are needed.

C. Notifying the charge nurse of the error is an important step, but checking the client's vital signs takes precedence to ensure the client's immediate safety. The charge nurse can be informed after the initial assessment.

D. Documenting the facts of the incident in the nurse's notes is important, but it comes after assessing the client and taking immediate actions to address any potential harm. Documenting the incident helps maintain a comprehensive record and contributes to the overall understanding of the event.

A. Perform CPR on the client. B. Assist with airway intubation. C. Maintain IV access. D. Place defibrillator pads on the client.

Correct Answer is A

Explanation

A. Perform CPR on the client:

CPR (Cardiopulmonary Resuscitation) is a critical and time-sensitive intervention during a cardiac arrest. An assistive personnel trained in CPR can initiate chest compressions while awaiting further medical assistance.

B. Assist with airway intubation:

Airway intubation is a more advanced skill typically performed by healthcare providers such as physicians or advanced practice nurses. It is beyond the scope of practice for most assistive personnel.

C. Maintain IV access:

Maintaining IV access may require specific skills and knowledge about medications and fluids. While some assistive personnel may be trained in certain aspects of IV care, the level of expertise needed during a cardiac arrest may be beyond their scope.

D. Place defibrillator pads on the client:

Applying defibrillator pads involves handling medical equipment and making critical decisions about when to deliver a shock. This task is typically performed by healthcare providers trained in advanced cardiac life support (ACLS).

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A nurse working in a long-term care facility is giving change-of-shift report on a client who had a stroke. Which of the following information should the nurse include in the report?

Nursing Test Bank

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