A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

"The client received morphine around lunch."

"The client had a lung biopsy 1 hour ago."

"Vital signs were obtained every 4 hours."

"The client's partner is at their bedside."

Answer and Explanation

The Correct Answer is B

A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.

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Correct Answer is A

Explanation

A. The nurse should complete an incident report and forward it to the risk manager within 24 hours as part of the facility’s protocol for reporting medication errors. This helps track errors, improve safety measures, and prevent future occurrences.
B. While a pharmacist may need to be involved in evaluating the error, there is no requirement to notify them within a specific timeframe. The priority is proper reporting and client monitoring.
C. Calling the nurse who made the error is not an appropriate action. Incident reports focus on improving systems rather than blaming individuals.
D. An incident report is not part of the medical record. It is an internal document used for quality improvement and risk management.

A. Administer the prescribed number of drops B. Apply gentle pressure to the client's punctum C. Tilt the client's head backward toward the ceiling D. Pull the client's lower lid down with the nondominant hand E. Verify the clarity and color of the eye drops

Correct Answer is E,C,D,A,B

Explanation

Verify the clarity and color of the eye drops. Ensuring the medication is not expired or contaminated is the first step in safe administration.
Tilt the client's head backward toward the ceiling. This position helps prevent the drops from draining out of the eye.
Pull the client's lower lid down with the nondominant hand. This creates a small pocket for the eye drops to be instilled properly.
Administer the prescribed number of drops. The medication should be placed in the conjunctival sac, not directly on the cornea.
Apply gentle pressure to the client's punctum. This prevents systemic absorption by blocking the nasolacrimal duct and reduces systemic side effects.

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A nurse is providing change-of-shift report about a client to an oncoming nurse. Which of the following information should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medication to a client and discovers that a nurse on the previous shift gave the client an incorrect dose of the medication. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is E,C,D,A,B

Explanation

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