A nurse is preparing to provide a change-of-shift report. Which of the following information should the nurse include in the report?

"Client in room 303 is requesting snacks between meals."

"Client in room 304 has a laptop that they use for relaxation."

"Client in room 302 has multiple visitors."

"Client in room 301 is in the cardiac catheterization lab."

Answer and Explanation

The Correct Answer is D

Rationale:

A. "Client in room 303 is requesting snacks between meals.": While client preferences are important, this information is non-urgent and can be communicated through care plans or written notes. It does not directly impact immediate nursing care during a shift change.

B. "Client in room 304 has a laptop that they use for relaxation.": This is personal, non-clinical information and is not essential for safe and effective handoff communication. Shift reports should focus on medical status, treatment plans, or immediate needs.

C. "Client in room 302 has multiple visitors.": Visitor status is not a priority item in a shift report unless it directly affects client care, safety, or monitoring. Including such information can distract from more clinically significant updates.

D. "Client in room 301 is in the cardiac catheterization lab.": This is critical information because it reflects a current procedure, potential risks, and possible post-procedure care needs. Reporting this ensures continuity of monitoring and prioritization.

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Correct Answer is C

Explanation

Rationale:

A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.

B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.

C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.

D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.

A. Check the label of the medication twice prior to administration. B. Use two identifiers to verify the client's identity. C. Document administration of the client's routine medications at the beginning of the shift. D. Ensure the medication is administered within 3 hr of the scheduled time.

Correct Answer is B

Explanation

Rationale:

A. Check the label of the medication twice prior to administration: Safe medication practice requires the nurse to check the medication label three times, when retrieving, preparing, and before administering to minimize the risk of medication errors.

B. Use two identifiers to verify the client's identity: Using two patient identifiers, such as name and date of birth, ensures the medication is given to the correct individual. This step is crucial for patient safety and is a core component of safe medication administration practices.

C. Document administration of the client's routine medications at the beginning of the shift: Medications should only be documented after they have been administered. Pre-charting medication administration can lead to errors if the medication is delayed, omitted, or refused.

D. Ensure the medication is administered within 3 hr of the scheduled time: Medications are typically required to be administered within 30 minutes to 1 hour of the scheduled time unless otherwise specified. A 3-hour window is too broad and may compromise therapeutic effectiveness.

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A nurse is preparing to provide a change-of-shift report. Which of the following information should the nurse include in the report?

Nursing Test Bank

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