When a night shift nurse completes a shift, she gives a report about h

QUESTION

When a night shift nurse completes a shift, she gives a report about her clients to the oncoming day shift nurse.

When beginning the report, the night shift nurse introduces herself and states her role, states the client’s name, identifiers, age, sex, and location. Which of the following should the nurse do next?

a. State critical lab reports, allergies, and alerts
b. List current medications and client’s family history
c. Talk about any anticipated changes in the plan of care
d. Relate client’s chief complaint, vital signs, symptoms, and diagnosis

ANSWER:

ANS: D
When using the acronym “I PASS the BATON,” the nurse should first introduce herself and state her role; then state the client’s name, identifiers, age, sex, and location; and then go over the client’s assessment, including the chief complaint, vital signs, symptoms, and diagnosis.
The fifth step in “I PASS the BATON” is safety concerns, which include critical lab reports, allergies, and alerts. The sixth step in “I PASS the BATON” is background, which includes comorbidities, previous episodes, current medications, and family history. The final step in “I PASS the BATON” is next, in which the plan is stated, including what will happen next, and includes any anticipated changes.