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.”
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Rationale:
• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.
• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.
Correct Answer is B
Explanation
Rationale:
A. Valerian root: Valerian root is primarily used for its sedative properties and is commonly recommended for sleep disorders or anxiety. It does not have evidence-based benefits for lowering cholesterol levels and is not appropriate for this client's condition.
B. Garlic: Garlic has been shown in some studies to modestly reduce total cholesterol and low-density lipoprotein (LDL) levels. It may also have antiplatelet effects, making it a relevant herbal supplement for clients with elevated cholesterol when used appropriately.
C. Aloe: Aloe is typically used topically for wound healing or orally for constipation. It is not known to have any significant effect on lipid levels and is not recommended for cholesterol management.
D. Saw palmetto: Saw palmetto is most commonly used for benign prostatic hyperplasia (BPH) symptoms in men. It has no known lipid-lowering effects and is not suitable for managing high cholesterol.
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