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","C"]

Explanation

Documentation should be done as soon as possible after an event has occurred, because this ensures accuracy, timeliness, and continuity of care.Documentation should include objective data (what the nurse observes or measures), subjective data (what the patient says or feels), and nursing interventions (what the nurse does or plans to do) to provide a clear picture of the patient’s condition and needs.Documentation should use abbreviations, symbols, and acronyms that are approved by the facility, because this promotes consistency, clarity, and compliance with legal and professional standards.

Choice D is wrong because documentation should not include opinions, judgments, or assumptions about the client’s condition, as these are not based on facts or evidence and may be biased or inaccurate.Documentation should be factual, accurate, and objective.

Choice E is wrong because documentation should reflect the nursing process and the standards of care, but this is not a complete statement.Documentation should also reflect the patient’s perspective, preferences, and goals.Documentation should be patient-centered, holistic, and individualized.

Normal ranges for clinical observations vary depending on the patient’s age, health status, and other factors.

However, some general ranges are:.

• Temperature: 36.5°C to 37.5°C.

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg or lower.

• Oxygen saturation: 95% or higher.

Sources:.

A. Subjective, Objective, Assessment, Plan. B. Situation, Observation, Action, Problem. C. Summary, Outcome, Analysis, Process. D. Source, Opinion, Accuracy, Purpose.

Correct Answer is A

Explanation

Subjective, Objective, Assessment, Plan.This is the meaning of SOAP format, which is a documentation method used by nurses and other healthcare providers to write out notes in the patient’s chart.

Choice B is wrong becauseSituation, Observation, Action, Problemis not a documentation method, but a communication tool used in handovers and briefings.

Choice C is wrong becauseSummary, Outcome, Analysis, Processis not a documentation method, but a framework for writing reflective essays.

Choice D is wrong becauseSource, Opinion, Accuracy, Purposeis not a documentation method, but a criteria for evaluating information sources.

SOAP format helps to organize the information collected from the patient in a clear and consistent manner.

It consists of four components:.

• Subjective: This includes how the patient is feeling and how they have been since the last review in their own words.

• Objective: This includes the objective observations that can be measured, seen, heard, felt or smelled, such as vital signs, fluid balance, clinical examination findings and investigation results.

• Assessment: This includes the thoughts on the salient issues and the diagnosis (or differential diagnosis) based on the subjective and objective data.

• Plan: This includes the actions that will be taken to address the patient’s problems, such as medications, investigations, referrals and follow-ups.

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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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Naxlex Comprehensive Predictor Exams

Which of these statements about documentation are true? (Select all that apply.).

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

Explanation

A nurse is using SOAP format to document a client’s progress note. What does SOAP stand for?

Correct Answer is A

Explanation

A nurse is using CBE documentation for a client who has diabetes mellitus. The nurse administers insulin to the client and documents this on a:.

A nurse is reviewing a critical pathway for a client who has chronic obstructive pulmonary disease (COPD). The nurse should understand that a critical pathway:.

A nurse is using accepted terminology and abbreviations when documenting the care of a client who has pneumonia and is receiving oxygen therapy via nasal cannula at 2 L/min. Which of the following abbreviations should the nurse use? (Select all that apply.).

A nurse is documenting an incident report for a medication error that occurred on her unit. Which of the following actions should the nurse take? (Select all that apply.).

A nurse is teaching a newly hired nurse about the legal aspects of documentation. Which of the following statements by the newly hired nurse indicates an understanding of the teaching?

What is one advantage of using a computerized system for documentation and reporting?

A nurse is working in an agency that uses EHR for documentation. Which of the following actions should the nurse take to ensure confidentiality and security of the client’s information? (Select all that apply.).

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?