A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

"The client in room 204 received some pain medicine earlier today."

"The client in room 205 has had several visitors."

"The client in room 205 is scheduled for a dressing change at 1800."

"The client in room 203 will undergo surgery at 0900 tomorrow."

"The client in room 204 has a new prescription for IV gentamicin."

Answer and Explanation

Correct Answer : C,D,E

A. "The client in room 204 received some pain medicine earlier today." is incorrect. This statement is not specific enough to be relevant during change-of-shift report, as the timing of medication administration is important for the next nurse to know and track. A more precise update would be more helpful.

B. "The client in room 205 has had several visitors." is incorrect. While visitation may be useful to mention if it affects the patient's condition or treatment, it's not essential information for the nurse taking over the care of the client.

C. "The client in room 205 is scheduled for a dressing change at 1800." is correct. This provides necessary information about a planned procedure and ensures the next nurse is aware of it for timely management.

D. "The client in room 203 will undergo surgery at 0900 tomorrow." is correct. This provides critical information regarding the client's schedule and helps the next nurse prepare for the upcoming surgery.

E. "The client in room 204 has a new prescription for IV gentamicin." is correct. This is important information for the next nurse, as it indicates a change in the client's treatment plan and ensures appropriate medication administration.

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Correct Answer is D

Explanation

A. Insertion of a nasogastric tube: While informed consent is important for many procedures, the insertion of a nasogastric (NG) tube is generally considered a routine procedure that may not require formal informed consent unless specific complications or risks are involved.

B. Administration of an iron injection using Z-track technique: Informed consent is typically required for procedures with inherent risks or invasive elements, but routine administration of iron injections is not typically classified as needing informed consent, unless there are specific concerns.

C. Irrigation of a wound with antibiotic solution: Irrigation of a wound is typically a low-risk procedure, and although it is important to inform the client about the treatment, it generally does not require formal informed consent unless there are complications or risks involved.

D. Placement of a central venous catheter: Informed consent is required for the placement of a central venous catheter, as it is an invasive procedure with potential risks such as infection, bleeding, and damage to blood vessels. This procedure requires the nurse to obtain and document the client's consent before proceeding.

A. "I'll take him back to the nursery, so you can get some rest." B. "If I turn him on his side, maybe he'll go back to sleep." C. "Babies need to cry soon after they are born to develop their lungs." D. "Let me show you how to swaddle and cuddle him, then you try."

Correct Answer is D

Explanation

A. Taking the newborn back to the nursery is incorrect. While rest is important for the mother, removing the baby does not help build her confidence or teach her how to respond to her infant’s needs. Supporting her in learning newborn care is more beneficial.

B. Turning the baby on his side to help him sleep is incorrect. The safest sleep position for a newborn is on the back, according to safe sleep guidelines. Additionally, this response does not address the mother's feelings of inadequacy.

C. Explaining that babies cry to develop their lungs is incorrect. While crying is normal for newborns, this response dismisses the client’s concern rather than providing reassurance and support.

D. Showing the mother how to swaddle and cuddle the baby, then letting her try is correct. This approach provides practical guidance and empowers the mother, helping her build confidence in her ability to care for her newborn.

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A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is D

Explanation

A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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