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 D

Explanation

A. Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

While a 24-hour urine collection is important for assessing kidney function, it is not an urgent task and can be scheduled at a later time without compromising the client's immediate well-being.

B. Change the dressing for a client who has a decubitus ulcer:

Changing the dressing for a decubitus ulcer is important for wound care, but it is not as urgent as addressing respiratory distress in a client with COPD.

C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering an antibiotic for a client with a methicillin-resistant Staphylococcus aureus (MRSA) infection is important, but it is not as immediately critical as ensuring adequate oxygenation in a client with COPD. Respiratory issues take precedence in the hierarchy of priorities.

D. Initiate oxygen therapy via nasal cannula for a client who has COPD.

The priority should be given to tasks that address immediate threats to the client's well-being or safety. In this scenario, initiating oxygen therapy for a client with COPD is a priority because it addresses respiratory distress and hypoxia, which are critical concerns in individuals with COPD. Respiratory interventions take precedence to ensure adequate oxygenation.

A. "Nonmaleficence is doing what is good for a client." B. "Fidelity means not doing anything that can harm the client." C. "Veracity means telling the truth and being honest." D. "Beneficence is being fair and impartial to a client."

Correct Answer is C

Explanation

A. The statement "Nonmaleficence is doing what is good for a client" is incorrect. Nonmaleficence is the ethical principle of "do no harm." It means avoiding actions that could harm the patient and ensuring that the benefits of treatment outweigh the potential risks.

B. The statement "Fidelity means not doing anything that can harm the client" is partially correct. Fidelity is the ethical principle of faithfulness and keeping promises. It involves being loyal to patients and maintaining trust. While it is related to avoiding harm, it specifically emphasizes keeping commitments and being trustworthy.

C. The statement "Veracity means telling the truth and being honest" is correct. Veracity is the ethical principle of truth-telling and honesty. It involves providing accurate and complete information to patients, promoting transparency in communication.

D. The statement "Beneficence is being fair and impartial to a client" is incorrect. Beneficence is the ethical principle of doing good for the patient, promoting their well-being, and advocating for their best interests. Fairness and impartiality are more aligned with the principle of justice.

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