A nurse is providing change-of-shift report on a client who is postoperative following abdominal surgery. Which of the following statements should the nurse include in the change-of-shift report?

"The client's postoperative antibiotic was administered."

"The client's partner came to visit today."

"At 2200, the client's IV fluid bag and tubing will need replacing."

"Colonoscopy was performed 48 hours ago."

Answer and Explanation

The Correct Answer is C

A. "The client's postoperative antibiotic was administered." While this information is important, it is not typically included in the change-of-shift report unless there were specific issues related to antibiotic administration (e.g., allergic reactions, missed doses).
B. "The client's partner came to visit today." While this information might be relevant to the client’s social and emotional well-being, it is not critical for the shift report regarding clinical care.
C. "At 2200, the client's IV fluid bag and tubing will need replacing." This statement is important for continuity of care and should be included in the report to ensure that the next shift is aware of necessary actions.
D. "Colonoscopy was performed 48 hours ago." This information is relevant for understanding the client’s postoperative status but is less immediate compared to other details such as current medication administration or upcoming needs.

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Correct Answer is A

Explanation

A. "If I continue to breathe in carbon monoxide, I could become unconscious." This is correct. Continued exposure to carbon monoxide can lead to unconsciousness and even death.
B. "If there is carbon monoxide in my house. I'll be able to smell it." This is incorrect. Carbon monoxide is a colorless and odorless gas, making it impossible to detect by smell.
C. "I have a gas furnace, so I don't have to worry about carbon monoxide." This is incorrect. Gas furnaces can produce carbon monoxide, especially if they are not properly ventilated or maintained.
D. "I will change the battery in my carbon dioxide detector every 2 years." This is incorrect. The batteries in carbon monoxide detectors should be changed more frequently, typically every 6-12 months, to ensure they function properly.

A. Offer the client hot chocolate or tea prior to rest periods. B. Encourage the client to ambulate in the hallway before resting. C. Cluster routine care activities to allow rest periods without interruptions. D. Encourage the client to watch television to relax.

Correct Answer is C

Explanation

A. Offer the client hot chocolate or tea prior to rest periods. While warm beverages can be comforting and help some people relax, hot chocolate and many teas contain caffeine, which can interfere with sleep. Even decaffeinated options might not be the best choice close to bedtime due to the fluid content, which could increase the need for nighttime urination, disrupting sleep.
B. Encourage the client to ambulate in the hallway before resting. Light physical activity, such as ambulating, can help promote relaxation and reduce muscle tension, which might aid sleep. However, it is essential to consider the client's postoperative status and ensure that ambulation is safe and appropriate for their condition. Overexertion close to bedtime might have the opposite effect and increase alertness.
C. Cluster routine care activities to allow rest periods without interruptions. This is a highly recommended intervention. By clustering care activities, the nurse can minimize disturbances during rest periods, allowing the client to have longer, uninterrupted sleep. This is crucial in a hospital setting where frequent interruptions can significantly impact the quality of sleep.
D. Encourage the client to watch television to relax. While watching television can be relaxing for some, it can also be stimulating and potentially interfere with sleep due to the light and noise. Blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. Therefore, this is generally not recommended as a sleep aid.

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A nurse is providing change-of-shift report on a client who is postoperative following abdominal surgery. Which of the following statements should the nurse include in the change-of-shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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