Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank

MULTIPLE CHOICE 1. The nurse is preparing the information that will be provided to the staf on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues? 1. Audit of client care procedures 2. The client’s diagnostic-related group 3. All routine care procedures required by the client 4. Instructions given to the client in a teaching plan ANS: 4 A change-of-shift report should include instructions given in a teaching plan and the client’s response. This should not include detailed content unless staf members ask for clarification. The nurse should relay to staf significant changes in the way therapies are given, but should not describe basic steps of a procedure. The client’s diagnosis-related group is not essential background information to be shared in an intershift report. The nurse should not review all routine care procedures or tasks. DIF: A REF: 399 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Safe, Efective Care Environment 2. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following? 1. The witnessing nurse completes the report. 2. Details of the incident are subjectively described. 3. An explanation of the possible cause for the incident is entered. 4. A notation is included in the medical record that an incident report was prepared.