Author Question: To locate the recording of a nurse's description of the teaching provided to the client on ... (Read 39 times)

itsmyluck · **on:** Jul 23, 2018

To locate the recording of a nurse's description of the teaching provided to the client on perfor-mance of self-medication administration, one would look in a(n):

1. Kardex
2. Incident report
3. Nursing history form
4. Discharge summary form

Question 2

The nurse is preparing the information that will be provided to the staff 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

meryzewe · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 4
A nurse's description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summary form. A Kardex is a written form that con-tains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give change-of-shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client.

Answer to Question 2

ANS: 4
A change-of-shift report should include instructions given in a teaching plan and the client's re-sponse. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not de-scribe basic steps of a procedure. The client's diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care pro-cedures or tasks.