A nurse is preparing to report a change in a client’s condition to another health care provider.

What should the nurse include in the report?

A summary of all the interventions performed since admission.

A description of how the nurse feels about the client’s situation.

A comparison of the client’s condition with other similar cases.

A statement of facts, changes, trends, and responses to treatment.

Answer and Explanation

The Correct Answer is D

A statement of facts, changes, trends, and responses to treatment. This is the best way to report a change in a client’s condition to another health care provider because it provides clear, concise, and relevant information that can help with decision making and continuity of care.

Choice A is wrong because a summary of all the interventions performed since admission is too broad and may not reflect the current situation of the client.

Choice B is wrong because a description of how the nurse feels about the client’s situation is subjective and may not be helpful for the other health care provider. Choice C is wrong because a comparison of the client’s condition with other similar cases is not specific to the individual client and may not account for differences in factors such as age, comorbidities, or preferences.

Normal ranges for vital signs, laboratory values, and other parameters may vary depending on the source and the context, but some common examples are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: less than 120/80 mm Hg.

• Oxygen saturation: greater than 95%.

• Blood glucose: 4.0 to 7.8 mmol/L (72 to 140 mg/dL).

• Hemoglobin: 13.5 to 17.5 g/dL for males, 12.0 to 15.5 g/dL for females.

• White blood cell count: 4.0 to 11.0 x 10^9/L.

• Platelet count: 150 to 400 x 10^9/L.

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Correct Answer is B

Explanation

“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.

A. Daily weight, blood pressure, and pulse B. Medication administration record. C. Nursing diagnosis and care plan. D. Discharge planning and referral summary.

Correct Answer is A

Explanation

Daily weight, blood pressure, and pulse.

A flow sheet is a type of document that records specific information in a structured and concise way, such as vital signs, fluid intake and output, pain level, etc.A flow sheet is useful for clinical communication and tracking the patient’s condition over time.A medication administration record (MAR) is a separate document that records the medications given to the patient, the dosage, the route, and the time.A nursing diagnosis and care plan is a document that identifies the patient’s problems and goals, and the interventions to achieve them.A discharge planning and referral summary is a document that outlines the patient’s needs and resources after leaving the facility, such as follow-up appointments, home care services, etc.

These documents are not part of a flow sheet.

Choice B is wrong because a MAR is not a flow sheet.

Choice C is wrong because a nursing diagnosis and care plan is not a flow sheet.

Choice D is wrong because a discharge planning and referral summary is not a flow sheet.

Normal ranges for daily weight vary depending on the patient’s age, height, gender, and medical condition.However, a general guideline is that a weight gain or loss of more than 2 kg (4.4 lbs) in a week or 0.9 kg (2 lbs) in a day may indicate fluid retention or dehydration.Normal ranges for blood pressure are less than 120/80 mmHg for adults, and less than 95/65 mmHg for children.Normal ranges for pulse are 60 to 100 beats per minute for adults, and 70 to 120 beats per minute for children.

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A nurse is preparing to report a change in a client’s condition to another health care provider. What should the nurse include in the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse is preparing to report a change in a client’s condition to another health care provider.

What should the nurse include in the report?