A nurse documents care given to the client during a shift. The client experienced a reduction in pain level while ambulating, took a shower, visited with family, and ate a small dinner
The nurse plans to include which information in the oral end-of-shift report? 1. The client's visit with family
2. The client's taking a shower
3. The last antibiotics given
4. The client's response to ambulation
4. The client's response to ambulation
Rationale:
In order to provide for the client's safety, the nurse would pass on the client's response to ambulation so that the oncoming staff can take fall precautions. Visiting with the family need not be mentioned at change of shift but should be documented. Taking a shower does not need to be reported, only documented. Antibiotics are reflected on the medication administration record (MAR). The nurse would also report any as-needed medications given and when they were last given.
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