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 C
Explanation
Choice A Reason:
Telling the client that their blood alcohol level will be checked is incorrect. Threatening the client with other forms of testing may not be ethically or legally appropriate, especially if the client has refused the initial request. It's important to respect the client's autonomy and right to refuse testing.
Choice B Reason:
Informing the client that a catheter will be inserted is incorrect. Inserting a catheter against the client's will is invasive and would constitute a violation of the client's autonomy and bodily integrity. It is not an appropriate action.
Choice C Reason:
Documenting the client's refusal in their chart is correct. Documenting the client's refusal is essential for accurate record-keeping and ensures that the healthcare team is aware of the client's decision. It also helps protect the nurse and the healthcare facility in case of any legal or ethical challenges related to the client's refusal.
Choice D Reason:
Assessing the client for urinary retention is incorrect. While urinary retention may be a concern in some cases, it is not the immediate action to take when a client refuses to provide a urine sample. The priority is to respect the client's autonomy and document their refusal appropriately. If there are clinical indications or concerns about urinary retention, they can be assessed separately and addressed accordingly.
Correct Answer is A
Explanation
Choice A Reason:
"I will have a client who is on airborne precautions wear a mask when out of her room." This statement demonstrates understanding of airborne precautions. Clients on airborne precautions, such as those with tuberculosis or measles, should wear a mask when they leave their room to prevent the spread of infectious droplets.
Choice B Reason:
"I will place a client who has compromised immunity in a negative-pressure airflow room." While placing a client with compromised immunity in a negative-pressure airflow room may be appropriate in some cases to reduce the risk of exposure to pathogens, it is not a standard precaution and is not applicable to all clients with compromised immunity.
Choice C Reason:
"I will instruct visitors to wear a mask when visiting a client who is on contact precautions." This statement indicates an understanding of contact precautions. Visitors should wear appropriate personal protective equipment, such as gloves and gowns, when visiting clients on contact precautions to prevent the transmission of infectious agents.
Choice D Reason:
"I will wear an N95 respirator mask when caring for a client who is on droplet precautions." This statement demonstrates understanding of droplet precautions. Healthcare providers should wear a surgical mask when caring for clients on droplet precautions, as it helps prevent the transmission of respiratory droplets generated by the client through coughing, sneezing, or talking. N95 respirator masks are typically reserved for airborne precautions.
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