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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A Reason:
A client who is at 32 weeks of gestation and has premature rupture of membranes is incorrect. This client is at risk for preterm labor and complications related to premature birth. Management involves monitoring for signs of labor, assessing fetal well-being, and potentially administering medications to prevent preterm labor. This requires obstetrical-specific knowledge and expertise.
Choice B Reason:
A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor is incorrect. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to organs, often the kidneys. Induction of labor in the setting of preeclampsia requires careful monitoring of maternal and fetal well-being, including blood pressure monitoring and fetal heart rate monitoring. Additionally, the use of misoprostol for induction requires understanding of its dosage, administration, and potential side effects, which are specific to obstetrical care.
Choice C Reason:
A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump is correct. This client is postoperative following a Cesarean section and is likely in need of pain management through a PCA pump. Postoperative care after a Cesarean section involves monitoring for signs of complications such as infection, bleeding, and wound healing, as well as managing pain effectively. While nurses with medical-surgical experience may be familiar with PCA pumps, the postoperative care of a cesarean section client involves obstetrical-specific considerations such as uterine monitoring, assessment of lochia (vaginal discharge after childbirth), and breastfeeding support.
Choice D Reason:
A client who has gestational diabetes and is receiving biweekly nonstress tests is incorrect. Gestational diabetes requires monitoring of maternal blood glucose levels and fetal well-being. Nonstress tests are a common method of assessing fetal well-being in pregnancies complicated by conditions such as gestational diabetes. Nurses caring for clients with gestational diabetes need to understand the management of blood glucose levels, dietary considerations, insulin administration if needed, and fetal monitoring techniques. This requires obstetrical-specific knowledge and expertise.

A. "A provider can write a prescription for restraints 'as needed"." B. "I should tie the restraints using a square knot." C. "I need to tie the restraint to the part of the bed frame that moves." D. "I will remove a client's restraints every 4 hours."

Correct Answer is B

Explanation

Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot.When applying restraints, using a square knot isessential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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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?