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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Free Nursing Study Resources

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

Explanation

A flow sheet is a type of document that recordsroutineandfrequentdata in agraphicalortabularform.It is used tomonitorandevaluatethe patient’s condition and response to treatment over time.A flow sheet should include information that isrelevant,conciseandeasy to read.

• Choice A is correct because vital signs are one of the most common and important data that need to be recorded and monitored regularly for any patient.

• Choice B is correct because allergies are essential information that can affect the patient’s treatment plan and prevent adverse reactions.

• Choice C is correct because medication administration is another crucial data that shows what drugs, doses, routes and times the patient has received or will receive.

• Choice D is wrong because medical history is not a routine or frequent data that needs to be recorded in a flow sheet.Medical history is usually documented in a separate form that provides more details and background information about the patient’s past and present health conditions.

• Choice E is correct because intake and output are important data that indicate the patient’s fluid balance and renal function.

They need to be recorded and monitored regularly, especially for patients who have fluid restrictions.

A. “I have an order for a chest x-ray for Mr. Jones in room 20.”. B. “Please repeat the order for a chest x-ray for Mr. Jones in room 20.”. C. “You want me to get a chest x-ray for Mr. Jones in room 20, right?.”. D. “I read back the order for a chest x-ray for Mr. Jones in room 20.”.

Correct Answer is D

Explanation

“I read back the order for a chest x-ray for Mr. Jones in room 20.”.

This is the best way to verify a telephone order from a radiologist, as it ensures that the nurse has accurately transcribed the order and that the radiologist has confirmed it.

Reading back the order also allows the nurse to clarify any doubts or questions about the order, such as the urgency, the reason, or the patient’s condition.

Choice A is wrong because it does not verify the order, but simply repeats it.

The nurse should not assume that the order is correct without confirmation from the radiologist.

Choice B is wrong because it asks the radiologist to repeat the order, which is inefficient and may cause confusion or errors.

The nurse should repeat the order to the radiologist, not the other way around.

Choice C is wrong because it uses a closed-ended question that can be answered with a yes or no, which may not reflect the radiologist’s true intention or understanding of the order.

The nurse should use an open-ended statement that requires the radiologist to acknowledge or correct the order.

According to federal regulations and accreditation standards, verbal and telephone orders should be authenticated by the prescriber within a specified time frame, usually 24 hours.Some states may have different or more stringent requirements, so nurses should be familiar with their state laws and regulations.Verbal and telephone orders should also be documented and signed by two nurses or one nurse and one enrolled endorsed nurse for verification and administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting a client’s admission assessment using a flow sheet. Which of the following information should be included in a flow sheet? (Select all that apply.).

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

Explanation

A nurse is taking a telephone order from a radiologist for a client who needs an urgent chest x-ray. Which of the following statements by the nurse is correct for verifying the order?

Correct Answer is D

Explanation

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A nurse is participating in a care plan conference for a client who has multiple chronic conditions and complex care needs. What is the main purpose of this meeting?

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?

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A nurse is using an electronic health record (EHR) system to document care for a client who has pneumonia. Which of the following is an advantage of using an EHR system?

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

A nurse is documenting the care provided to a client who receives home health services. Which of the following records should the nurse use to certify that the client meets Medicare eligibility criteria and to outline the services to be provided?

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?