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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: This is not the correct choice because witnessing the client signing the consent form is not a valid option. The client is a minor and cannot legally consent to their own treatment without the permission of their guardian, unless they are emancipated, married, or pregnant.

Choice B reason: This is not the correct choice because asking the adult neighbor to sign the consent form is not a valid option. The adult neighbor is not a legal guardian or a close relative of the client and has no authority to consent to the client's treatment.

Choice C reason: This is not the correct choice because obtaining consent from the hospital administrator is not a valid option. The hospital administrator is not a medical professional or a legal representative of the client and has no authority to consent to the client's treatment.

Choice D reason: This is the correct choice because attempting to notify the client's guardian to obtain consent is the best option. The client's guardian is the person who has the legal right and responsibility to make decisions for the client's health care. The nurse should try to contact the guardian by phone or other means and obtain verbal or written consent for the emergency surgery. If the guardian cannot be reached, the nurse should follow the facility's policy and procedure for obtaining consent in emergency situations.

A. Contact the client's next of kin to obtain consent for treatment. B. Proceed with treatment without obtaining written consent. C. Have the client sign a consent for treatment. D. Notify risk management before initiating treatment.

Correct Answer is B

Explanation

Choice A reason: Contacting the client's next of kin to obtain consent for treatment is not a correct action, as it may delay the necessary and urgent care for the client. The nurse should assume that the client would consent to life-saving treatment and act in the client's best interest.

Choice B reason: Proceeding with treatment without obtaining written consent is the correct action, as it is justified by the emergency doctrine. The nurse should provide immediate and appropriate care for the client who is unable to give consent due to their condition.

Choice C reason: Having the client sign a consent for treatment is not a correct action, as the client is disoriented and cannot give informed consent. The nurse should not ask the client to sign any documents that they may not understand or remember.

Choice D reason: Notifying risk management before initiating treatment is not a correct action, as it is not a priority in an emergency situation. The nurse should focus on the client's needs and safety and document the care provided and the rationale for the actions taken.

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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?

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