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: This is not the correct choice because an increase in serosanguineous exudate (a mixture of blood and clear fluid) from a client's wound indicates infection, inflammation, or trauma to the wound. This is a sign of wound deterioration, not healing.
Choice B reason: This is the correct choice because a deep red color on the center of a client's wound indicates granulation tissue, which is new tissue that forms during the healing process. Granulation tissue fills the wound bed and provides a foundation for epithelialization (the growth of new skin over the wound).
Choice C reason: This is not the correct choice because erythema (redness) on the skin surrounding a client's wound indicates irritation, inflammation, or infection of the skin. This is a sign of wound complication, not healing.
Choice D reason: This is not the correct choice because inflammation on the tissue edges of a client's wound indicates infection, trauma, or necrosis (death) of the tissue. This is a sign of wound impairment, not healing.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because this client has the highest risk of injury or death in the event of a fire. The client is confused and may not understand the situation or follow instructions. The client is also restrained and cannot move or escape without assistance. The nurse should evacuate this client first and remove the restraints as soon as possible.
Choice B reason: This is not the correct choice because this client has a moderate risk of injury or death in the event of a fire. The client is postoperative and has a chest tube, which may limit their mobility and require special equipment. However, the client is not confused or restrained and can cooperate with the evacuation process. The nurse should evacuate this client after the confused and restrained client.
Choice C reason: This is not the correct choice because this client has a low risk of injury or death in the event of a fire. The client is in Buck's traction, which is a type of skin traction that does not require pins or wires. The client can be easily moved by releasing the weights and securing the traction to the bed. The nurse should evacuate this client after the postoperative and chest tube client.
Choice D reason: This is not the correct choice because this client has the lowest risk of injury or death in the event of a fire. The client is receiving IV chemotherapy, which is a treatment that can be stopped and resumed later. The client is also ambulatory, which means they can walk and move without assistance. The nurse should evacuate this client last or ask them to evacuate themselves.
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