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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decreased impulsiveness. Methylphenidate is a CNS stimulant used to treat ADHD. It helps improve attention, focus, and impulse control, which indicates the medication's effectiveness.
B. Decreased abdominal pain. Abdominal pain is a possible side effect of methylphenidate, but its resolution does not indicate the medication’s effectiveness in treating ADHD.
C. Increased appetite. Methylphenidate commonly suppresses appetite rather than increasing it. Increased appetite would not indicate effectiveness.
D. Increased urine output. Methylphenidate does not significantly affect urine output, so this is not a sign of its effectiveness.
Correct Answer is B
Explanation
A. Simply documenting the client's lack of understanding does not address their immediate need for clarification. The nurse must take action.
B. The provider is responsible for obtaining informed consent and ensuring the client understands the procedure. The nurse should notify the provider so they can provide the necessary explanation.
C. Discussing other treatment options is beyond the nurse’s scope of practice. Only the provider should discuss alternative treatments.
D. The nurse can reinforce teaching but cannot provide new information about the surgery. Since the client is unsure about the procedure, the provider must explain it.
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