A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
The time the client received his last dose of pain medication
The client's preferred time for bathing
The steps to follow when providing wound care
The belief that the client has a difficult relationship with his son
The Correct Answer is C
Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
"I will have a nurse witness the signing of my living will." This statement is incorrect. While having a witness present during the signing of a living will is important for validity in some jurisdictions, the statement alone does not demonstrate an understanding of advance directives. It's essential to ensure that the client comprehends the purpose and content of the document, not just the procedural aspect.
Choice B Reason:
"I can make changes to my living will even after I sign it." This statement is correct. Understanding that living wills can be revised or updated as needed reflects comprehension of the flexibility and control that advance directives provide. It's crucial for clients to know that they can make changes to their directives if their preferences or circumstances change.
Choice C Reason:
"I should choose a family member as my health care proxy." This statement is incorrect. While selecting a family member as a health care proxy is a common choice, it may not necessarily indicate an understanding of advance directives. The key aspect is that the client understands the role of the health care proxy and chooses someone who can make decisions aligned with their wishes.
Choice D Reason:
"I need to have my attorney review my advance directives." This statement is incorrect. While it can be beneficial to have an attorney review advance directives for legal clarity and compliance with state laws, it is not a requirement for their validity. The statement alone does not demonstrate understanding of advance directives.
Correct Answer is C
Explanation
Choice A Reason:
Listing names of witnesses to the fall in the nurses' notes is incorrect. While it's important to document witnesses to the fall, listing their names in the nurses' notes is not the primary action related to incident reporting. Witness information is typically included in the incident report itself.
Choice B Reason:
Sending the incident report to the ethics committee is incorrect. Incident reports are typically submitted to the appropriate department within the healthcare facility responsible for managing incidents and ensuring appropriate follow-up. Sending the incident report to the ethics committee may not be necessary unless there are specific ethical concerns related to the incident.
Choice C Reason:
Includes the client's account of the fall in the incident report is correct. When a client falls, it's essential to document the incident accurately and thoroughly. Including the client's account of the fall in the incident report demonstrates an understanding of the procedure because it provides valuable information about the circumstances surrounding the fall from the client's perspective.
Choice D Reason:
Documenting in the client's record that an incident report was filed is incorrect. Documenting in the client's record that an incident report was filed is a necessary step, but it doesn't provide detailed information about the incident itself. The incident report itself should contain comprehensive details about the fall, including the client's account, witnesses, actions taken, and any resulting injuries.
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