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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"I cannot confirm or deny that we have a client by that name." is correct. Respecting patient confidentiality is crucial in healthcare. Revealing any information about a patient's condition without proper authorization or consent could breach confidentiality laws, such as HIPAA (Health Insurance Portability and Accountability Act) in the United States. Therefore, providing minimal to no information over the phone to an unidentified caller is the appropriate approach to safeguard the patient's privacy.
Choice B Reason:
"I will tell him you called." Is incorrect. This response implies that the nurse will pass along the information or the fact that the employer called, potentially breaching the patient's confidentiality by confirming the client's presence in the hospital to an unauthorized person.
Choice C Reason:
"The client's condition is stable right now." Is incorrect. Revealing any information about the patient's condition to someone who hasn't been authorized to receive such information can breach patient confidentiality. Even stating that the condition is stable discloses some level of the patient's health status without proper consent.
Choice D Reason:
"He is here in the hospital, but I cannot tell you anything else." Is incorrect. While this response acknowledges the patient's presence in the hospital, it also hints that the nurse has information about the patient. It doesn't adhere to the standard of patient confidentiality, potentially breaching the patient's privacy.
Correct Answer is ["A","B","C","D","E"]
Explanation
1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.
2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.
3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.
4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.
5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.
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