A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

"He appears anxious about the transfer."

"He is allergic to sulfa."

"His partner has been visiting."

"He is voiding adequately."

Answer and Explanation

The Correct Answer is B

Choice A Reason:

"He appears anxious about the transfer."While this might be relevant in certain contexts, it is subjective and less critical compared to other clinical information. The transfer report should prioritize objective data that directly impacts the client’s care.

Choice B Reason:

"He is allergic to sulfa." Allergies are crucial information that must be communicated during any transfer. This ensures that the receiving healthcare team is aware and can avoid administering medications that could cause an allergic reaction. This is important information to include in the transfer report.

Choice C Reason:

"His partner has been visiting." While it may be helpful to know about the client’s support system, this information is not as critical as details about the client's health status, medications, or allergies.

Choice D Reason:

"He is voiding adequately." Voiding patterns can be relevant, particularly if there have been recent issues with urinary function or if the client is being monitored for urinary output. However, unless there is a specific reason this is critical to ongoing care, it may not be the most essential information to include.

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Correct Answer is D

Explanation

Choice A Reason:

Turn on loud music in client care areas is incorrect. This action might increase stress rather than reduce it. Loud noises or music can be distressing for clients, especially in a healthcare setting where rest and recovery are crucial. It's generally better to maintain a calm and quiet environment.

Choice B Reason:

Assign different nurses to provide care for clients each day is incorrect. Continuity of care is often beneficial for clients, as it fosters trust and familiarity. Having different nurses daily might disrupt this continuity and potentially increase stress for clients who prefer consistent caregivers.

Choice C Reason:

While offering some choices can empower clients and reduce stress, too many choices might overwhelm them, particularly in an acute care setting. The key is to provide a balance of autonomy while not overwhelming the client.

Choice D Reason:

Limiting the number of visitors can help create a quieter, more controlled environment, reducing overstimulation and stress for clients. This can be particularly important in an acute care setting where rest and a calm environment are crucial for recovery.

A. Recheck the client's SaO, level after having the client cough and clear their throat. B. Review the client's most recent Sao, level in the medical record. C. Notify the charge nurse of the client's condon. D. Check the client's medical records to see which medications were recently administered.

Correct Answer is A

Explanation

Choice A Reason:

Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.

Choice B Reason:

Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.

Choice C Reason:

Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.

Choice D Reason:

Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.

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A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

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Naxlex Comprehensive Predictor Exams

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