A nurse is providing a change-of shift report about a client who is 36 hr postoperative to another nurse. Which of the following information should the nurse include in the report?
Client was nauseated immediately after surgery.
Client's pain relieved by position change.
Checked for peripheral IV blood return prior to antibiotic.
Client provided with breakfast tray at 0800.
The Correct Answer is B
A. Client was nauseated immediately after surgery: While postoperative nausea is important to document, it is an event that occurred in the past and may not reflect the client’s current status 36 hours after surgery.
B. Client’s pain relieved by position change: This information is critical as it reflects the current effectiveness of nonpharmacologic pain management strategies and guides ongoing care for comfort.
C. Checked for peripheral IV blood return prior to antibiotic: This is a routine nursing task that was completed. While important for safe medication administration, it's a procedural detail of a completed task and not usually included in a concise shift report.
D. Client provided with breakfast tray at 0800: Although documenting nutrition is important, the exact timing of meal delivery is less significant than clinical status information during shift handoff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. The client slept 5 hr the previous night: Acute manic episodes often involve severe sleep deprivation, sometimes going days without sleep. Achieving 5 hours of rest indicates reduced hyperactivity and a positive response to treatment.
B. The client takes 2 short naps during the day: While napping may seem beneficial, in manic clients it can indicate ongoing disrupted sleep-wake cycles. Full, restorative nighttime sleep is a more reliable sign of improvement.
C. The client consumes 8 oz of high-calorie fluids each hour: During mania, clients often neglect nutritional needs. Actively consuming adequate fluids suggests improved awareness, cooperation, and decreased impulsivity.
D. The client engages in quiet activities in their room: Initially, the client was extremely restless and disruptive. Choosing calm, solitary activities reflects improved impulse control and reduced manic energy.
E. The client appears to listen to unseen others: This suggests persistent auditory hallucinations, indicating that psychotic symptoms remain present and untreated or only partially managed. This is not a sign of improvement.
Correct Answer is B
Explanation
A. Leave the room to initiate a rapid response: Leaving the client alone during a seizure places them at high risk for injury. The nurse should remain with the client to provide immediate safety interventions and call for help without leaving the bedside.
B. Loosen any clothing around the client's neck: Loosening clothing helps maintain an open airway and reduces the risk of choking or airway obstruction during the seizure, making it a priority intervention.
C. Place the client in a high-Fowler’s position: High-Fowler’s position is inappropriate during a seizure because it increases the risk of falling or injury. The client should be placed on their side to promote drainage of secretions and reduce aspiration risk.
D. Apply a bite block in the client's mouth: A bite block should never be inserted during an active seizure due to the risk of injuring the mouth or airway. It can only be used before a seizure in specific circumstances, if prescribed.
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