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 C

Explanation

A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

A. Measure and record the client's leg circumferences daily. B. Place the client with their knees in a sharply flexed position. C. Monitor the client's RBCs every 4 hr. D. Administer warfarin PO daily.

Correct Answer is A

Explanation

A. Measure and record the client's leg circumferences daily. This is correct because measuring leg circumference helps assess for changes in swelling and monitor the progression or improvement of deep-vein thrombosis.
B. Place the client with their knees in a sharply flexed position. This is incorrect because sharply flexing the knees can impede blood flow and increase the risk of clot formation. The client should be encouraged to keep their legs extended and slightly elevated.
C. Monitor the client's RBCs every 4 hr. This is incorrect because deep-vein thrombosis does not typically require frequent RBC monitoring. Instead, coagulation studies such as PT, aPTT, and INR are more relevant.
D. Administer warfarin PO daily. This is incorrect because warfarin is contraindicated during pregnancy due to its teratogenic effects. Instead, low-molecular-weight heparin or unfractionated heparin is the preferred anticoagulant during pregnancy.

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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?

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