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 A
Explanation
Choice A reason: This is an incorrect action by the unit nurse. Alcohol-based hand sanitizer is not effective against Clostridium difficile spores, which can cause severe diarrhea and colitis. The nurse should wash their hands with soap and water after removing gloves to prevent the spread of the infection.
Choice B reason: This is a correct action by the unit nurse. Wearing goggles when emptying the bedpan of liquid stool is a standard precaution that protects the nurse's eyes from exposure to body fluids. The nurse should also wear gloves and a gown when handling the bedpan.
Choice C reason: This is a correct action by the unit nurse. Placing the client in contact precautions is an appropriate measure for clients who have Clostridium difficile. Contact precautions prevent direct or indirect transmission of the infection through contact with the client or the client's environment. The nurse should use a single room or cohort the client with another client who has the same infection.
Choice D reason: This is a correct action by the unit nurse. Cleaning contaminated equipment with bleach-based solution is an effective way to kill Clostridium difficile spores, which can survive on surfaces for a long time. The nurse should follow the manufacturer's instructions for the dilution and contact time of the bleach solution.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.