A nurse is getting ready for a change-of-shift report. What information should the nurse include?
Medication routine from the medication administration record
Bone scan scheduled for today
Blood pressure from the previous day
Input and output for the shift
The Correct Answer is D
Choice A reason: While medication administration is important, the routine from the MAR is not typically included in a shift report unless there are specific concerns such as missed doses, adverse reactions, or changes in medication orders. The focus should be on current and relevant information.
Choice B reason: Scheduled procedures like a bone scan may be mentioned if they are critical to the client’s care plan or require preparation, but they are not the primary focus of a shift report unless they impact immediate nursing care.
Choice C reason: Vital signs from the previous day are outdated for a shift report. The report should include the most recent and relevant data to guide the incoming nurse’s care decisions.
Choice D reason: Input and output for the shift are essential components of the shift report. They provide insight into the client’s fluid balance, renal function, and potential complications such as dehydration or fluid overload, which are critical for ongoing assessment and care planning.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Admission assessments require comprehensive evaluation and clinical judgment, which are within the RN’s scope of practice. LPNs do not perform initial assessments or admissions for complex conditions such as renal failure.
Choice B reason: Chest tube insertion is an invasive procedure requiring advanced clinical skills and sterile technique. Assisting with this procedure is typically reserved for RNs or specially trained personnel.
Choice C reason: Monitoring a client with chest pain and pending cardiac enzyme results involves critical thinking and interpretation of lab data, which is outside the LPN’s scope. This task should be handled by an RN.
Choice D reason: LPNs are trained to perform routine wound care and dressing changes for stable postoperative clients. A client who is 2 days post-op from a total hip arthroplasty is typically stable, making this task appropriate for an LPN.
Correct Answer is A
Explanation
Choice A reason: A living will is a legally binding document that outlines a client's preferences regarding lifesaving and end-of-life medical interventions. It becomes effective when the client is incapacitated or unconscious and unable to communicate their wishes. The nurse should affirm that the living will reflects the client’s predetermined decisions and must be respected by healthcare providers and family members.
Choice B reason: The durable power of attorney for health care (DPOA-HC) is authorized to make decisions only within the scope allowed by the living will. They cannot override or cancel the living will unless the document itself grants them that authority. Most living wills do not permit cancellation by the DPOA-HC once the client is incapacitated.
Choice C reason: The Patient Self-Determination Act (PSDA) mandates that healthcare institutions inform patients of their rights to make advance directives. However, it does not grant family members the right to change lifesaving measures once a living will is in effect. This statement misrepresents the PSDA’s role.
Choice D reason: A case manager does not have legal authority to alter a client’s living will. Their role is to coordinate care and resources, not to make or change medical decisions outlined in legal documents.
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