A nurse is giving a change of shift report to the nurse on the next shift.

Which of the following statements by the nurse is appropriate for handoff communication?

“The client in room 12 is very demanding and complains a lot.”.

“The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”.

“The client in room 16 is allergic to penicillin and sulfa drugs.”.

“The client in room 18 is a 65-year-old male who had a myocardial infarction yesterday.”.

Answer and Explanation

The Correct Answer is B

“The client in room 14 has a wound dressing that needs to be changed at 10 a.m.”

This statement is appropriate for handoff communication because it provides relevant and specific information about the patient’s care plan and any pending tasks that need to be completed by the next nurse.

It also allows for the opportunity for discussion and clarification between the nurses.

Choice A is wrong because it is subjective and disrespectful to the patient.

It does not convey any useful information about the patient’s condition, needs, or preferences.

It may also create a negative bias or impression on the next nurse, which could affect the quality of care.

Choice C is wrong because it is not timely or relevant for handoff communication.

The patient’s allergies should be documented in the electronic health record (EHR) and verified with the patient before administering any medications.

It is not necessary to repeat this information during every handoff, unless there is a change or concern.

Choice D is wrong because it is too vague and incomplete for handoff communication.

It does not provide any details about the patient’s current status, vital signs, medications, interventions, or goals.

It also does not indicate any anticipated changes or potential complications that the next nurse should be aware of.

Handoff communication is a critical element of patient safety and continuity of care.

It involves the transfer of essential patient data from one caregiver to another during transitions of care across the continuum. It should be interactive, accurate, concise, and standardized. Some examples of handoff communication tools are SBAR (Situation, Background, Assessment, Recommendations), I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, Next), ISHAPED (Introduction, Story, History, Assessment, Plan, Error prevention, Dialogue), and kardex.

These tools help to structure and organize the information exchange between providers and ensure that nothing is missed or misunderstood.

References:.

: 12 patient handoff communication tools to know - Becker’s ASC.

: Handoff communication - standardizing nursing protocols.

: Communication Strategies for Patient Handoffs | ACOG.

: 8 Tips for High-quality Hand-offs - The Joint Commission.

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Correct Answer is ["A","B"]

Explanation

Kardexes and flow sheets are types of records that are used for documenting concise data about a client and making information quickly accessible to all health professionals.Kardexes are a series of cards kept in a portable index file or on computer generated forms that contain a problem list, stated goals and list of nursing approaches to meet the goals.Flow sheets are forms that allow for recording routine aspects of care such as vital signs, intake and output, medications, etc.

Choice C is wrong because progress notes are not concise, but rather narrative descriptions of the client’s condition, interventions and outcomes.Choice D is wrong because nursing discharge summaries are not used for quick access, but rather for providing information about the client’s hospitalization, treatment and follow-up care.Choice E is wrong because care plan conferences are not records, but meetings where health professionals discuss the client’s needs, goals and progress.

Normal ranges for vital signs are as follows:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respiration: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mmHg.

A. Include factual information about what happened. B. State opinions about who was responsible for the error. C. File the report in the client’s medical record. D. Notify the risk management department. E. Discuss possible solutions to prevent future errors.

Correct Answer is ["A","D"]

Explanation

The nurse should include factual information about what happened and notify the risk management department.These actions are part of the steps of reporting medication errorsand the good practice guide on recording, coding, reporting and assessment of medication errors.

Choice B is wrong because the nurse should not state opinions about who was responsible for the error.

This could be seen as biased, unprofessional or accusatory.

The nurse should focus on the facts and the causes of the error, not on blaming individuals.

Choice C is wrong because the nurse should not file the report in the client’s medical record.

This could violate the client’s privacy and confidentiality.

The report should be filed in a separate system that is accessible only to authorized personnel.

Choice E is wrong because the nurse should not discuss possible solutions to prevent future errors.

This could be premature, unrealistic or inappropriate.

The nurse should leave this task to the investigation team or the risk management department, who will analyse the incident and make recommendations based on evidence and best practice.

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A nurse is giving a change of shift report to the nurse on the next shift. Which of the following statements by the nurse is appropriate for handoff communication?

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Explanation

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A nurse is giving a change of shift report to the nurse on the next shift.

Which of the following statements by the nurse is appropriate for handoff communication?