A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

"The client's partner visited earlier today for 2 hours."

"The client received the prescribed antibiotic every 8 hours."

"The client's mother died 4 years ago from breast cancer."

"The client reports pain is reduced when he is positioned on his side.”

Answer and Explanation

The Correct Answer is D

Rationale:

A. "The client's partner visited earlier today for 2 hours.": While documenting visitors can be relevant in certain psychosocial or safety contexts, this detail is not critical to clinical decision-making or continuity of care during shift handoff.

B. "The client received the prescribed antibiotic every 8 hours.": Routine administration of scheduled medications does not need to be reported unless there are concerns like adverse reactions, missed doses, or changes in therapy. Simply stating adherence to the schedule adds little value to clinical communication.

C. "The client's mother died 4 years ago from breast cancer.": Past family history may be relevant to the medical record, but it does not impact immediate clinical care or require prioritization during a shift change report unless it is directly influencing current treatment decisions.

D. "The client reports pain is reduced when he is positioned on his side.”: This is current, subjective, and actionable information that informs the incoming nurse about effective pain management strategies and contributes to patient comfort and care planning.

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Correct Answer is A

Explanation

Rationale:

A. Maintain the client in high-Fowler's position: Placing the client in high-Fowler's position improves lung expansion and decreases pulmonary congestion by lowering venous return to the heart. This is a priority intervention for managing dyspnea and crackles in heart failure.

B. Increase the client's intake of oral fluids: Increasing fluid intake may worsen fluid overload in clients with heart failure. These clients typically require fluid restrictions to prevent exacerbation of symptoms like pulmonary edema.

C. Instruct the client to cough every 4 hr: While coughing can help clear secretions, the symptoms in this scenario are related to fluid overload, not mucus accumulation. Coughing alone will not relieve the pulmonary congestion seen in heart failure.

D. Encourage the client to ambulate to loosen secretions: Ambulation has benefits but is not the first action when the client is short of breath and showing signs of pulmonary congestion. Activity should be limited until respiratory status stabilizes.

A. Tonic-clonic satures B. Sleep apnea C. Paresthesias D. Disorientation

Correct Answer is D

Explanation

Rationale:

A. Tonic-clonic seizures: Tonic-clonic activity is induced during the ECT procedure itself but typically resolves within seconds. It is not expected to persist 15 minutes post-procedure, as seizure activity is carefully controlled and monitored during the treatment.

B. Sleep apnea: While general anesthesia used during ECT can cause brief respiratory depression, sleep apnea is not a typical or expected consequence of the procedure. Continuous monitoring ensures airway patency during and immediately after treatment.

C. Paresthesias: Numbness or tingling sensations (paresthesias) are not common side effects of ECT. The procedure affects brain activity and cognition rather than peripheral nerves, making this symptom unlikely post-treatment.

D. Disorientation: Temporary confusion or disorientation is a common and expected side effect shortly after ECT. It typically resolves within 30 to 60 minutes as the effects of anesthesia wear off, and it is routinely monitored during recovery.

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A nurse is providing change-of-shift report for a client. Which of the following information should the nurse include in the report?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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