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 steps to follow when providing wound care
The client's preferred time for bathing
The belief that the client has a difficult relationship with his son
The Correct Answer is B
Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.
Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.
Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.
Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreased cost-effectiveness is not an outcome of critical pathway use, but rather an outcome of poor quality care. Critical pathways are designed to improve the quality and efficiency of care by reducing unnecessary costs and resources.
Choice B reason: Decreased care delays is an outcome of critical pathway use, as it reflects the timely and coordinated delivery of care. Critical pathways are evidence-based plans that outline the expected course of care and outcomes for a specific client population.
Choice C reason: Increased length of stay is not an outcome of critical pathway use, but rather an outcome of ineffective or inappropriate care. Critical pathways are intended to shorten the length of stay by optimizing the care process and preventing complications.
Choice D reason: Increased variation in clinical interventions is not an outcome of critical pathway use, but rather an outcome of inconsistent or individualized care. Critical pathways are meant to standardize the clinical interventions based on the best available evidence and practice guidelines.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the most urgent and potentially life-threatening problem. Urinary retention after spinal surgery can lead to bladder distension, infection, renal damage, or autonomic dysreflexia (a dangerous rise in blood pressure and heart rate). The nurse should assess the client's bladder, catheterize the client if indicated, and notify the surgeon.
Choice B reason: This is not the correct choice because this client has a serious but not urgent problem. Pancreatic cancer is a malignant tumor that can affect the function of the pancreas and other organs. IV chemotherapy is a treatment that uses drugs to kill cancer cells. The nurse should provide emotional support, education, and symptom management to this client, but they are not the highest priority.
Choice C reason: This is not the correct choice because this client has a chronic but not acute problem. Peripheral vascular disease is a condition that affects the blood vessels outside the heart and brain, causing reduced blood flow to the limbs. An absent pedal pulse indicates poor circulation in the foot, which can lead to pain, numbness, or tissue damage. The nurse should monitor the client's pulses, skin temperature, and color, and teach the client how to prevent complications, but they are not the highest priority.
Choice D reason: This is not the correct choice because this client has a stable but not critical problem. MRSA is a type of bacteria that is resistant to many antibiotics and can cause skin or systemic infections. An axillary temperature of 38°C (101°F) indicates a mild fever, which is a common sign of infection. The nurse should administer antibiotics as prescribed, observe the client for signs of sepsis, and follow infection control precautions, but they are not the highest priority.
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