The client in room 108 has been prescribed new pain medication.
A nurse is providing change-of-shift report to the oncoming nurse.
Which of the following information should the nurse include in the report?
The family of the client in room 107.
The client in room 105 had a bath.
The client in room 108 received a new pain medication.
The dietary preferences of the client in room 109.
The Correct Answer is C
Choice A rationale
Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.
Choice B rationale
While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.
Choice C rationale
The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.
Choice D rationale
The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Developing a care plan is a collaborative process that ideally involves the physician, the patient, the nurse, and other members of the healthcare team. The physician's input is vital for medical diagnoses, treatment orders, and overall medical management, which are integral components of the patient's comprehensive care plan.
Correct Answer is D
Explanation
Choice A rationale
Informing the patient that the urinary output goal was not met, without further investigation, does not address the underlying cause of the low output and fails to implement necessary interventions. It is a superficial action that lacks a scientific basis for improving the patient's condition.
Choice B rationale
Contacting the physician for a diuretic order without first assessing the cause of the reduced urinary output could be premature and potentially harmful. Diuretics increase urine production but may not be appropriate if the low output is due to dehydration, decreased renal perfusion, or other factors. Normal urine output is typically 0.5 to 1 mL/kg/hour.
Choice C rationale
Changing the goal to match the current inadequate output is inappropriate as it lowers the standard of care and fails to address a potentially serious underlying physiological issue. The initial goal of 80 mL/hour likely reflects the patient's needs based on their condition and weight.
Choice D rationale
Reassessing the patient is the most appropriate initial action. This allows the nurse to gather crucial data such as vital signs, hydration status, medication history, and any factors that might be contributing to the decreased urinary output. Understanding the cause is essential for implementing targeted and effective interventions.
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