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.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A reason: This is not the correct choice because recommending the son meet with the provider to get information about his mother's condition is not the first action the nurse should take. The nurse should first stop the unauthorized access to the client's records and protect the client's privacy and confidentiality. The nurse can then offer to arrange a meeting with the provider if the son has questions or concerns.
Choice B reason: This is not the correct choice because completing an incident report regarding the breach of the client's confidentiality is not the first action the nurse should take. The nurse should first intervene to prevent further disclosure of the client's information and secure the computer. The nurse can then document the incident and follow the facility's policy and procedure for reporting such events.
Choice C reason: This is the correct choice because logging out the computer so that the client's son is unable to view his mother's information is the first action the nurse should take. The nurse should act quickly and assertively to terminate the unauthorized access to the client's records and safeguard the client's rights. The nurse should also explain to the son why his action was inappropriate and how it violated the client's confidentiality.
Choice D reason: This is not the correct choice because reporting the possible violation of client confidentiality to the nurse manager is not the first action the nurse should take. The nurse should first address the immediate situation and ensure that the client's information is no longer accessible to the son. The nurse can then inform the nurse manager and the provider about the incident and the actions taken.
Correct Answer is B
Explanation
Choice A reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction or a skin infection, which are not life-threatening conditions. The nurse should monitor the client for signs of anaphylaxis or systemic infection, but this client is not the highest priority.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority because they are at risk of hemorrhage and shock. The nurse should apply direct pressure to the wound, elevate the affected leg, and monitor the client's vital signs and hemoglobin level.
Choice C reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac or pulmonary problem, such as angina, myocardial infarction, or pulmonary embolism, which are serious conditions. The nurse should obtain an electrocardiogram, administer oxygen, and prepare for further diagnostic tests and interventions, but this client is not the highest priority.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a renal or urinary problem, such as kidney stones, pyelonephritis, or renal colic, which are painful but not life-threatening conditions. The nurse should administer analgesics, encourage fluid intake, and collect a urine sample, but this client is not the highest priority.
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