A client presents to the medical surgical unit.

Which of the following findings requires further action by the nurse? Select all that apply.

A) *The client's partner visited earlier today for 2 hours: While this information is helpful for the personal context of the client, it is not essential to the clinical care of the client or a critical part of the handoff. The change-of-shift report should focus on relevant clinical information that affects ongoing care, such as treatment responses, medications, or changes in condition.

B) "The client reports pain is reduced when he is positioned on his side": This is important clinical information that should be included in the report. It provides insight into the client’s current comfort measures and pain management strategies. Sharing how the client’s pain can be alleviated will help the next nurse provide the most effective care and manage the client's comfort.

C) "The client received the prescribed antibiotic every 8 hours": While medication administration is an essential part of the report, this specific detail is unnecessary if the medication administration schedule is already part of the client's medical record or the nurse's medication administration documentation. The change-of-shift report should focus on whether the client has had any reactions, responses, or issues related to the medication, rather than simply repeating the schedule.

D) "The client's mother died 4 years ago from breast cancer": This personal history may be relevant to understanding the client's emotional well-being but is not essential in a clinical report unless it directly impacts current care. If the client's grief or family history affects their current health status (such as in the case of emotional distress, family health risks, or health behaviors), it may be relevant, but it's generally not a priority in a shift report unless it has immediate implications for care.

A. Chronic health condition: The client has a history of Parkinson’s disease and anxiety, which are relevant but not immediate concerns. Chronic conditions require long-term management rather than urgent intervention.
B. Current level of consciousness: The client is restless and not following commands, which may indicate hypoxia, worsening infection, or sepsis. A change in mental status is a critical finding requiring immediate evaluation.
C. Oxygen saturation level: The oxygen saturation is 89% on room air, which is below the normal range (≥95%). This suggests respiratory compromise, likely due to pneumonia, requiring urgent oxygen support.
D. Heart rate: The client has a heart rate of 104/min, which is mildly elevated and expected due to fever and respiratory distress. However, it is not the most critical concern compared to respiratory distress and altered mental status.
E. Respiratory rate: The respiratory rate is 30/min, indicating tachypnea and increased work of breathing, suggesting respiratory distress or impending respiratory failure. This requires immediate intervention.
F. Tremors: Tremors are a common finding in Parkinson’s disease and do not require immediate intervention.