What data are necessary to compile an effective end-of-shift report? (Select all that apply.)

Patients mental status

All pertinent nursing care

Visitors the patient had during the shift

Status of lung sounds

The patients favorite TV shows

Answer and Explanation

Correct Answer : A,B,D

A.   The patient's mental status is crucial for understanding their current cognitive and emotional condition. This information helps the incoming nurse assess whether there have been any changes or concerns regarding the patient's orientation, mood, or cognitive function.
B.   Documenting all pertinent nursing care provides a comprehensive overview of what has been done for the patient during the shift, including any treatments, medications administered, and changes in the patient's condition.
C.   While knowing who visited the patient might be relevant in some contexts, it is generally not a core component of clinical shift reports unless the visitors' presence impacted patient care or the patient’s condition. This information is usually not necessary for the shift report unless it directly affects the
patient’s care or treatment, such as if a visitor brought important information or had a significant impact on the patient.

D.   The status of lung sounds is a specific aspect of the patient's physical assessment and can indicate respiratory issues or improvements. This data is necessary if the patient has a respiratory condition or if there have been recent changes in their respiratory status. It helps the incoming nurse evaluate the effectiveness of treatments and ongoing respiratory care.
E.   Information about the patient's favorite TV shows is not relevant to clinical care and does not impact
the patient’s health status or the nursing interventions required. This information is not necessary for
the shift report as it does not contribute to the patient’s medical or care needs.

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Correct Answer is D

Explanation

A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.

A. Would you drink to relax after a particularly stressful day? B. Have you ever experienced a memory loss as a result of consuming alcohol? C. Do you ever drink when you are alone? D. How many alcoholic drinks do you consume each week?

Correct Answer is D

Explanation

A. While this question may provide some insight into the patient's drinking habits, it is not as direct and informative as asking about the quantity of alcohol consumed.
B. This question may reveal a history of alcohol-related problems, but it does not provide information about the patient's current drinking habits.
C. While this question may be relevant in some cases, it is not a universal indicator of alcohol abuse. Many people may drink alone without having a problem with alcohol.
D. To assess an older adult's risk potential for alcohol abuse, it is important to get a sense of their drinking habits. Asking about the number of alcoholic drinks consumed each week is a direct and informative way to assess their drinking patterns.

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What data are necessary to compile an effective end-of-shift report? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patient's:

Correct Answer is D

Explanation

An older adult patient is being assessed for possible alcohol abuse. To best assess the patient's risk potential, the nurse asks:

Correct Answer is D

Explanation

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