Which of the following statements are true regarding hand-off reports? Select the 3 correct answers.
Must be given face to face between the nurses.
Provides for the continuity and individualized care of the patient.
Must include an opportunity for the receiver to ask querry of the person giving the report.
Includes up-to-date and recent changes about the patient.
Takes the place of documentation.
Correct Answer : B,C,D
Choice A rationale
While face-to-face hand-off reports are often preferred for direct communication and clarification, they are not always the only acceptable method. Other methods, such as recorded reports or written summaries with opportunities for questions, can also be effective in ensuring continuity of care, especially in situations where face-to-face reporting is not feasible.
Choice B rationale
Providing for the continuity and individualized care of the patient is a primary purpose of hand-off reports. By sharing relevant information about the patient's current condition, care plan, and any recent changes, the hand-off ensures that the receiving nurse has the necessary information to provide consistent and tailored care.
Choice C rationale
Including an opportunity for the receiver to ask questions of the person giving the report is crucial for effective communication and to clarify any ambiguities or obtain additional details. This interactive element helps ensure that the receiving nurse fully understands the patient's situation and can provide safe and appropriate care.
Choice D rationale
Hand-off reports should include up-to-date and recent changes about the patient's condition, treatments, and any new orders or concerns. This ensures that the receiving nurse is aware of the most current information and can adjust care accordingly. Outdated information can lead to errors or omissions in care.
Choice E rationale
Hand-off reports supplement, but do not replace, formal documentation in the patient's medical record. Documentation provides a comprehensive and permanent record of the patient's care, while the hand-off report is a verbal or brief written communication to ensure a smooth transition of care between nurses. Both are essential for effective patient care and communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice B rationale
Reinserting a urinary catheter requires a physician's order as it is an invasive procedure that falls outside the scope of independent nursing practice. Catheterization carries risks of infection and trauma, necessitating medical authorization.
Choice D rationale
Administering a medication, even a mild stool softener, requires a physician's prescription. Nurses cannot independently prescribe or initiate medication therapy. This intervention is based on a medical order to manage or prevent constipation.
Choice A rationale
Calculating fluid intake and output is a routine nursing assessment and monitoring activity that nurses perform independently to evaluate a patient's hydration status and kidney function. It does not require a physician's order.
Choice C rationale
Encouraging fluid and fiber intake are independent nursing interventions aimed at promoting healthy bowel function. Nurses can educate patients and suggest lifestyle modifications without a direct physician's order.
Choice E rationale
Assessing the abdomen for distention, bowel sounds, and tenderness is a physical assessment skill that nurses use independently to gather data about a patient's gastrointestinal system. It is a part of the nursing assessment process.
Correct Answer is D
Explanation
Choice A rationale
This is a direct quote from the client, providing subjective data about their difficulty with the syringe markings. Documenting client statements verbatim, enclosed in quotation marks, offers valuable insight into their perspective and experiences.
Choice B rationale
This is an objective finding, reporting a specific laboratory value (Fasting Blood Sugar). Documenting numerical data with units of measurement is essential for tracking trends and assessing the client's condition. The normal range for FBS is typically 70-100 mg/dL.
Choice C rationale
This documents an observed skill and the client's ability to perform a specific task correctly. Documenting observed behaviors and skills demonstrates the client's learning and competence in self-care activities.
Choice D rationale
The phrase "seems to be more comfortable" is a subjective interpretation by the nurse rather than an objective observation or a direct client statement. Documentation should primarily focus on factual observations, client statements, and measurable data rather than the nurse's personal opinions or assumptions.
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