A nurse is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide a report to the oncoming nurse?
Outside client's room
Conference area
Nurse's lounge
Client's bedside
The Correct Answer is D
Choice A reason: Outside client's room is not an appropriate area to provide report to the oncoming nurse. This area may not be private or quiet enough to ensure confidentiality and accuracy of the information. The nurse may also miss important cues or changes in the client's condition or environment.
Choice B reason: Conference area is not an appropriate area to provide report to the oncoming nurse. This area may be too far from the client's room or the nursing station, which can delay the response time or the continuity of care. The nurse may also lose the opportunity to interact with the client and the family, and to verify the data with the physical assessment.
Choice C reason: Nurse's lounge is not an appropriate area to provide report to the oncoming nurse. This area may be too informal or distracting to maintain the professionalism and focus of the report. The nurse may also violate the privacy and dignity of the client and the family by discussing their personal or medical information in a public place.
Choice D reason: Client's bedside is an appropriate area to provide report to the oncoming nurse. This area allows the nurse to involve the client and the family in the report, which can enhance their satisfaction, safety, and education. The nurse can also observe the client's condition and behavior, and perform the physical assessment and the medication reconciliation with the oncoming nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Telephone number is an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, telephone number is one of the approved patient identifiers that can be used to reliably identify the individual as the person for whom the service or treatment is intended. Telephone number is a person specific identifier that is unlikely to be shared by another client.
Choice B reason: Room number is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, room number is not an example of a unique patient identifier. Room number is not a person specific identifier, but a location specific identifier that can change or be assigned to another client.
Choice C reason: Medical condition is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, medical condition is not an example of a unique patient identifier. Medical condition is not a person specific identifier, but a health specific identifier that can be common or vague among different clients.
Choice D reason: Home address is not an acceptable identifier to use to identify the client. According to the Safety and Quality Improvement Guide Standard 5: Patient Identification and Procedure Matching, home address is not an example of a unique patient identifier. Home address is not a person specific identifier, but a place specific identifier that can be shared or changed by the client.
Correct Answer is A
Explanation
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
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