A nurse working in a long-term care facility is giving change-of-shift report on a client who had a stroke. Which of the following information should the nurse include in the report?

The client's blood pressure was recorded at 0730 and 1130.

The client's pain medication was administered twice during this shift.

The client's enteral feeding bag needs to be changed at 2200.

The client received a bath and backrub.

Answer and Explanation

The Correct Answer is A

A. The client's blood pressure was recorded at 0730 and 1130.

In a change-of-shift report, it is important to communicate vital signs, especially changes in the client's condition. Recording the blood pressure at different times during the shift helps the oncoming nurse understand the client's cardiovascular status and identify trends or potential issues.

B. The client's pain medication was administered twice during this shift:

While medication administration is important information, specifying the number of times pain medication was administered may be less relevant in a brief change-of-shift report. It's more critical to communicate the client's pain level, response to medication, or any concerns related to pain management.

C. The client's enteral feeding bag needs to be changed at 2200:

While enteral feeding is an essential aspect of care, the timing of the feeding bag change may not be as crucial in a change-of-shift report. Instead, it would be more pertinent to communicate any issues related to the client's tolerance of feeding, any changes in feeding rate, or signs of intolerance.

D. The client received a bath and backrub:

Personal care activities, such as a bath and backrub, are essential components of nursing care, but they may be less critical in a change-of-shift report unless there are specific concerns related to the client's skin condition or overall well-being. More emphasis should be placed on clinical assessments and changes in the client's condition.

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Correct Answer is B

Explanation

A. Inserting a straight urinary catheter for a client:

Inserting a urinary catheter involves a sterile procedure and requires the specialized skills of a licensed nurse. This task should not be delegated to assistive personnel.

B. Performing perineal care for a client who has an indwelling urinary catheter.

Delegating tasks should align with the education, training, and scope of practice of the assistive personnel. Performing perineal care for a client with an indwelling urinary catheter is a task that can be appropriately delegated to assistive personnel. This task involves basic hygiene and does not require the advanced skills or knowledge of a licensed nurse.

C. Showing a client how to use an incentive spirometer:

Educational tasks, such as demonstrating how to use an incentive spirometer, require knowledge and understanding of the device, as well as the ability to assess and respond to the client's needs. This task is best performed by a licensed nurse.

D. Increasing oxygen flow for a client who has a nasal cannula:

Adjusting oxygen flow involves assessing the client's condition and making decisions based on the client's oxygenation needs. This task requires the clinical judgment of a licensed nurse and should not be delegated to assistive personnel.

A. Informed consent B. Do-not-resuscitate order C. Advance directives D. Provider's prescription

Correct Answer is C

Explanation

A. Informed consent:

While informed consent may include information about the surgical procedure and potential risks, it typically does not address organ donation. Organ donation is usually a separate decision and may be documented in advance directives.

B. Do-not-resuscitate order:

A do-not-resuscitate (DNR) order specifies the client's wishes regarding resuscitation in the event of cardiac or respiratory arrest but does not contain information about organ donation.

C. Advance directives.

Advance directives are legal documents that outline a person's preferences for medical treatment in the event they become unable to communicate or make decisions for themselves. Within advance directives, individuals may express their wishes regarding organ donation. It's common for individuals to specify their desire to be an organ donor in these documents.

D. Provider's prescription:

A provider's prescription is a medical order for a specific treatment or medication. It does not typically contain information about organ donation, which is a personal decision made by the individual and documented in advance directives.

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A nurse working in a long-term care facility is giving change-of-shift report on a client who had a stroke. Which of the following information should the nurse include in the report?

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