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.
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Related Questions
Correct Answer is C
Explanation
A. Trim the fat from red meat prior to cooking: Children with cystic fibrosis often require higher fat intake due to malabsorption, so removing fat is not recommended unless medically indicated for another reason.
B. Give the child hot foods to reduce the sense of fullness: There is no physiological basis to suggest that giving hot foods reduces a sense of fullness in children with cystic fibrosis. Large volumes or very hot/cold foods could potentially exacerbate gastrointestinal discomfort. fullness is more effectively managed with enzyme support and meal planning.
C. Provide a diet high in protein and calories: Due to increased energy needs and poor nutrient absorption, children with cystic fibrosis benefit from a high-calorie, high-protein diet to support growth and maintain weight.
D. Administer pancreatic enzymes 30 min after meals: Pancreatic enzymes should be given just before or at the start of meals to aid digestion effectively. Giving them 30 minutes after eating would not support optimal nutrient absorption.
Correct Answer is D
Explanation
A. Sacrum: The sacrum is typically assessed for pressure injuries but is not the most reliable site for detecting cyanosis in clients with dark skin because of variable pigmentation.
B. Shoulders: The shoulders have significant pigmentation and are not ideal for assessing cyanosis in dark-skinned clients due to difficulty distinguishing color changes.
C. Area of trauma: Trauma sites may show redness or bruising unrelated to cyanosis, making them unreliable for assessing oxygenation status.
D. Palms of the hands: The palms have less melanin and are lighter in color, making them a better site to observe for cyanosis in clients with dark skin due to clearer visualization of bluish discoloration.
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