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:

"I will rinse the contaminants from a bedpan with hot water." Is incorrect. Rinsing contaminants with hot water might not be sufficient for proper disinfection and could potentially contribute to the spread of infection. Proper disinfection methods involve using appropriate cleaning agents or disinfectants.

Choice B Reason:

"I will double-bag a client's linens each day." Is incorrect. While containing soiled linens is important, double-bagging might not necessarily be a standard practice for managing linens unless there's a specific protocol or contamination issue. It might not be directly related to infection control principles.

Choice C Reason:

"I will wear sterile gloves when bathing a client who is incontinent." Is incorrect. Wearing sterile gloves for routine bathing of an incontinent client is not typically necessary. Using clean gloves or standard precautions would generally be appropriate unless there's a specific medical procedure requiring sterile technique.

Choice D Reason:

"I will use disinfectant to clean the blood pressure cuff after use on a client." Is correct. Using a disinfectant to clean equipment, especially after use on a client, is a key infec

A. Apply intermittent suction for up to 30 seconds. B. Preoxygenate the client prior to suctioning. C. Instruct the client to swallow during catheter insertion. D. Apply suction while inserting the catheter.

Correct Answer is B

Explanation

Choice A Reason:

Applying intermittent suction for up to 30 seconds is incorrect. While suctioning is necessary for tracheostomy care, the duration and frequency of suctioning should be based on the client's need and should typically last no more than 10-15 seconds to prevent hypoxemia and tissue damage.

Choice B Reason:

Preoxygenate the client prior to suctioning is correct. Preoxygenation helps ensure that the client has adequate oxygen levels before the suctioning procedure, reducing the risk of hypoxemia or decreased oxygen levels during and after suctioning

Choice C Reason:

Instruct the client to swallow during catheter insertion is incorrect. Instructing the client to swallow during catheter insertion is not a standard procedure for tracheostomy care. Swallowing doesn't have a direct association with the suctioning process.

Choice D Reason:

Apply suction while inserting the catheter is incorrect. Applying suction during catheter insertion can cause tissue damage and should be avoided. Suction should only be applied when withdrawing the catheter to remove secretions from the tracheostomy tube.

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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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