after receiving change-of-shift report, which patient will the nurse assess first?

Which of the following patients should the nurse assess first? The nurse should use the ABCs to determine which order to assess the patients. The nurse should assess the 48-year-old patient with respiratory problems first (shortness of breath and pulse oximeter reading of 88%).

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What does the nurse learn about aspiration pneumonia during change of shift?

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a.

How does a nurse teach an older female patient with heart failure?

The nurse working on the heart failure unit knows that teaching an older female patient with newly diagnosed heart failure is effective when the patient states that a. she will take furosemide (Lasix) every day at bedtime. b. the nitroglycerin patch is to be used when chest pain develops.

What should the nurse do if the QRS interval increases?

Check the medical record for the most recent potassium level. ANS: D The increasing QRS interval is suggestive of hyperkalemia, so the nurse should check the most recent potassium and then notify the patient's health care provider.

What should the nurse do if the patient is having trouble breathing?

Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.

Which client should the nurse assess first after receiving a change-of-shift report?

Which client should the nurse on the vascular unit assess first after receiving the shift report? The client with an above the knee amputation who needs a full body lift to get in the wheelchair. The charge nurse of a long-term care facility is making assignments.

Which of the following clients should the nurse assess first?

Which of the following clients should the nurse assess first? *When using the acute versus chronic approach to client care, the nurse should place the priority on the client who has a chest tube and has asymmetrical chest movement because this can indicate a tension pneumothorax.

Which of the following should be included in the change-of-shift report?

Change-of-Shift Report Should: Include significant objective information about the client's health problems. Proceed in a logical sequence. Include no gossip or personal opinion.

Which information is most informative when giving a change-of-shift report?

In giving a change-of-shift report, which type of client information communicated by the nurse is most appropriate? Rationale: A change-of-shift report should include significant changes (good or bad) in a client's condition. The information should be accurate, concise, clear, and complete.

Which client does the nurse assess first after receiving Morning Report?

WHICH CLIENT SHOULD THE NURSE ASSESS FIRST AFTER MORNING REPORT? Expiratory wheezes should be seen first as may indicate allergic reaction to the contrast.

In what order should the nurse assess assigned clients following shift Report place in priority order?

Terms in this set (59) In what order should the nurse assess assigned clients following shift report? Place in priority order.

What is change of shift report in nursing?

Change-of-shift report is the time when responsibility and accountability for the care of a patient is transferred from one nurse to another. The communication that ensues during this process is linked to both patient safety and continuity of care giving.

Why is shift report important in nursing?

Shift report, when completed at the patient bedside, allows the nurse to visualize and assess the patient and the environment, as well as communicate with and involve the patient in the plan of care.

What is the purpose of a shift report?

Shift reports help improve communication between coworkers or team members, and they ensure proper execution, control and oversight. Managers use shift reports to pass information about proceedings that take place during a specific shift to others.

Who is responsible for giving the end of shift report on the unit?

The LPN/LVN is responsible for giving end-of-shift reports. There are several types of reporting systems.

How do you give a patient a report?

18:5620:45How to Give a Nursing Shift Report - YouTubeYouTubeStart of suggested clipEnd of suggested clipSo you always just want to know who the family is and if you don't always look through the chart ifMoreSo you always just want to know who the family is and if you don't always look through the chart if the nurse doesn't know look through the chart. Because believe it or not to the patient.

How do you write the end of a shift report?

Tips for an Effective End-of-Shift ReportUse Concise and Specific Language. ... Record Everything. ... Conduct Bedside Reporting as Often as Possible. ... Reserve Time to Answer Questions. ... Review Orders. ... Prioritize Organization. ... The PACE Format. ... Head to Toe.

What should a nurse check for in ARDS?

The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

How long after heart surgery does a patient develop dyspnea?

The other drugs are appropriate for the patient with ARDS. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with.

What does it mean when your respiration drops to 10 breaths?

The patient's respirations have dropped to 10 breaths/minute. ANS: D. A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive-pressure ventilation is needed.

What causes a drop in oxygen saturation in the blood?

Elevated temperature increases metabolic demands and oxygen use by tissues, resulting in a drop in oxygen saturation of central venous blood. Information about the patient's body mass index, urinary output, and lipase will not help in determining the cause of the patient's drop in ScvO2.

Should ICU visitation be individualized?

ICU visiting should be individualized to each patient and family rather than being dictated by rigid visitation policies. Inviting the family to participate in a multidisciplinary conference is appropriate but should not be the initial action by the nurse.

Can family members remain in the room during CPR?

Research indicates that family members want the option of remaining in the room during procedures such as cardiopulmonary resuscitation (CPR) and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient. Click again to see term 👆.

What should a nurse assess for?

The nurse should immediately assess this patient for other findings such as dyspnea or chest pain. The findings in the other patients are typical of their diagnoses and do not indicate a need for urgent assessment and intervention.

Does dilated cardiomyopathy cause heart failure?

Because dilated cardiomyopathy does not respond well to therapy, even patients with good compliance with therapy may have recurrent episodes of heart failure . Elevation of the legs above the heart will worsen symptoms (although this approach is appropriate for a patient with hypertrophic cardiomyopathy).