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.
His partner has been visiting.
He is voiding adequately.
He is allergic to sulfa.
The Correct Answer is D
Choice A rationale
He appears anxious about the transfer provides subjective information about the client's emotional state. While important, it's not essential for the transfer report which typically focuses on objective, actionable data.
Choice B rationale
His partner has been visiting is valuable for understanding the client's support system, but it does not directly affect the client's clinical care during transfer.
Choice C rationale
He is voiding adequately offers relevant information about the client's bodily function, important for ongoing care but not as critical as allergy information.
Choice D rationale
He is allergic to sulfa provides essential medical information that can affect the client's treatment plan. Knowing allergies is crucial to prevent adverse reactions to medications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Verbal consent alone is not sufficient for invasive procedures like urinary catheter insertion. Documented consent is necessary to ensure legal and ethical compliance.
Choice B rationale
Having another nurse co-sign the consent does not verify the client's explicit agreement to the procedure. It is important that the client’s direct consent is documented.
Choice C rationale
Checking the medical record for a previous consent form may not reflect the client's current willingness. Consent should be obtained fresh to confirm current understanding and agreement.
Choice D rationale
Witnessing the client's signature on a consent form ensures that the client has been informed and agrees to the procedure, fulfilling both legal and ethical requirements.
Correct Answer is C
Explanation
Choice A rationale
Using a narrower cuff can result in an inaccurate blood pressure reading by providing artificially high values due to increased pressure on a smaller surface area.
Choice B rationale
Requesting a prescription for an antihypertensive medication is premature without verifying the accuracy of the initial blood pressure measurement and considering other factors that might have influenced the reading.
Choice C rationale
Measuring the client's blood pressure in the other arm can help confirm the initial reading. Differences in readings between arms can occur, and a second measurement ensures accuracy and proper assessment.
Choice D rationale
Deflating the cuff faster when repeating the blood pressure measurement can lead to inaccurate readings. The cuff should be deflated at a standard rate to ensure reliability and accuracy in the measurement. .
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