A nurse is giving change-of-shift report about a client who is 36-hr postoperative to another nurse. Which of the following should the nurse include?
Daily bath given at 1000
Vomited a large amount of emesis immediately after surgery
Flushed IV with 0.9% sodium chloride
Pain relieved by position change
The Correct Answer is D
A. Routine activities such as daily baths are not typically pertinent information to include in a change-of-shift report unless they have a significant impact on the client's condition or care.
B. While vomiting after surgery may be noteworthy, the timing and amount of emesis
immediately after surgery may not be relevant to the client's current condition, especially if it was an isolated incident.
C. Flushing the IV with normal saline is a routine nursing intervention and may not be necessary to report unless there were specific concerns or complications related to the IV.
D. Pain relief is an important aspect of postoperative care and should be included in the report to ensure continuity of care and appropriate pain management for the client.
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Related Questions
Correct Answer is B
Explanation
A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.
B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be
indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.
C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.
D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.
Correct Answer is A
Explanation
A.
A. Justice refers to fairness and equity in the distribution of resources and the treatment of
individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.
B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.
C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.
D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.
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