A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? (Select all that apply)

Preferred bath time.

Admission vital signs.

Time of last pain medication.

Steps required for dressing change.

Answer and Explanation

Correct Answer : C,D

The correct answers are C and D.

Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.

Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.

Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.

Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.

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Correct Answer is D

Explanation

Choice A rationale:

Replace the IV pump's tubing. Replacing the IV pump's tubing is not the appropriate action when the IV pump screen is malfunctioning. Malfunctioning tubing does not typically affect the pump's screen or settings.

Choice B rationale:

Clear the settings and reset the IV pump. Clearing the settings and resetting the IV pump may not be effective if the screen is malfunctioning. It is important to ensure the accuracy and safety of IV fluid administration, and troubleshooting the screen is not a reliable solution in the case of a malfunction.

Choice C rationale:

Plug the IV pump's cord into a different outlet. Changing the outlet may help if the issue is related to electrical power, but it is not the most appropriate action when the IV pump screen is malfunctioning. Safety concerns and potential equipment issues warrant discontinuing use and tagging the pump.

Choice D rationale:

Discontinue use and tag the IV pump. When the IV pump screen is malfunctioning, the safest and most appropriate action is to discontinue its use and tag the pump. This ensures that the malfunctioning equipment is not used on other patients and that a thorough inspection and repair can be conducted to prevent potential harm to the patient.

A. A client who has psychomotor retardation. B. A client who reports an inability to concentrate. C. A client who exhibits an increase in energy. D. A client who experiences persistent insomnia.

Correct Answer is C

Explanation

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

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A nurse is preparing to give change-of-shift report on a client who is 2 days postoperative following a total knee arthroscopy. Which of the following information should the nurse include in the report? (Select all that apply)

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Correct Answer is D

Explanation

A nurse is collecting data from a group of clients who have major depressive disorder. The nurse should identify that which of the following clients is at the greatest risk for suicide?

Correct Answer is C

Explanation

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