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 A

Explanation

A. Identify current infection rates from facility data:

This is the correct answer. Before implementing any changes, it is crucial to assess the current state of infection rates within the facility. This data serves as a baseline to measure the effectiveness of interventions.

B. Incorporate the process change into daily practice within the facility:

This step comes after identifying the current infection rates. Implementing changes without understanding the baseline infection rates may not effectively address the issue.

C. Select a potential intervention to lower the current infection rate:

While selecting an intervention is a crucial step, it should follow the identification of current infection rates. Interventions should be evidence-based and tailored to the specific issues identified.

D. Determine if the implemented change has lowered the current infection rate:

This step occurs after the intervention has been implemented. It involves ongoing monitoring and evaluation to determine the impact of the changes on infection rates.

A. A staff member places a midstream urine sample in a specimen refrigerator after-collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster. D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture

Correct Answer is D

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it:

This is a proper practice. Refrigerating the sample after collection helps preserve its integrity and prevents bacterial growth until it can be analyzed.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill:

This is a proper infection control practice. Chlorhexidine is an effective disinfectant, and cleaning the area following a blood spill helps prevent the spread of infectious agents.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster:

This is a proper practice. Alcohol-based antiseptic is effective in killing a broad spectrum of germs, and hand hygiene is crucial, especially after contact with a client who may have an infectious condition.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture:

This is an infection control hazard. Sterile saline irrigation should not be poured onto an open wound before specimen collection, as it can introduce contaminants and interfere with the accuracy of culture results. Specimens should be collected using aseptic technique to avoid contamination.

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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?

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Correct Answer is D

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