A nurse is providing a handoff report to the oncoming shift nurse. Which of the following actions should the nurse take to ensure continuity of client care?
Encourage the oncoming shift nurse to contact the provider with any questions.
Record a verbal report on a recorder for the oncoming nurse to listen to.
Use a standardized approach to giving the handoff report.
Provide the handoff report at the nurses' station.
The Correct Answer is C
Rationale
A. Encourage the oncoming shift nurse to contact the provider with any questions: While the oncoming nurse may need to contact the provider, relying on this step alone does not ensure a comprehensive or standardized handoff. Important information may be missed if the report is informal or incomplete.
B. Record a verbal report on a recorder for the oncoming nurse to listen to: Using a recording is not ideal because it prevents real-time clarification and questions. Direct communication is necessary to address immediate concerns and confirm understanding for safe continuity of care.
C. Use a standardized approach to giving the handoff report: Utilizing a standardized method, such as SBAR (Situation, Background, Assessment, Recommendation), ensures that essential information is communicated clearly, consistently, and completely. This approach reduces errors and promotes continuity of care between shifts.
D. Provide the handoff report at the nurses' station: Providing a report at the nurses’ station may compromise privacy and lead to distractions. Bedside handoff or a private setting allows for a more thorough and interactive exchange of information, supporting safety and continuity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is a normal postoperative finding during the first few hours after surgery. It reflects expected wound healing and does not require immediate reporting.
B. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period due to anesthesia and analgesics. While bowel function should be monitored, this finding is expected and not urgent.
C. Urine output 25 mL/hr: Urine output below 30 mL/hr indicates possible inadequate renal perfusion or early postoperative oliguria. This finding should be reported promptly to the provider for evaluation and potential intervention to prevent acute kidney injury.
D. Heart rate 68/min: A heart rate within normal limits is not concerning in a postoperative client. It does not indicate a complication and does not require immediate provider notification.
Correct Answer is B
Explanation
Rationale
A. "My hearing has improved since I got my hearing aids.": This statement reflects a positive adaptation to age-related sensory changes and does not indicate a disturbed body image. The client demonstrates acceptance and use of assistive devices to maintain function.
B. "I avoid going out because I sometimes have problems with incontinence.": Avoiding social situations due to incontinence suggests the client is experiencing distress or embarrassment about physical changes, reflecting an impaired body image. This avoidance can affect self-esteem, social engagement, and overall quality of life.
C. "These lines in my face reveal a part of my character.": This statement shows the client has a positive perception of aging and views physical changes as meaningful rather than negative, indicating a healthy body image.
D. "My wrinkled hands show how hard I've worked all my life.": The client interprets physical aging positively, associating wrinkles with experience and effort, which demonstrates acceptance of bodily changes and a preserved body image.
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