A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?

The emergency department nurse is waiting to give report on a new admission.

Two staff members have called to say they will be absent.

Transport assistance is unavailable to take a client to occupational therapy.

A nurse on the previous shift wrote an incident report about a medication error.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the correct choice because this situation is the most urgent and requires immediate action. The charge nurse should prioritize the new admission and assign a staff nurse to receive the report and prepare the room for the client. The charge nurse should also ensure that the client's needs are met and that the admission process is smooth and efficient.

Choice B reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should plan the staffing for the shift and arrange for replacements or reassignments if necessary. The charge nurse should also communicate with the staff members who called in and document their reasons for absence.

Choice C reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should coordinate with the transport department and the occupational therapy department to reschedule the client's appointment or find an alternative way to transport the client. The charge nurse should also inform the client and the staff nurse about the change and apologize for any inconvenience.

Choice D reason: This is not the correct choice because this situation is not as urgent as the new admission and can be addressed later. The charge nurse should review the incident report and follow up with the nurse who wrote it and the client who was involved. The charge nurse should also implement corrective actions and preventive measures to avoid similar errors in the future.

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Correct Answer is B

Explanation

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.

A. Diminished hand-to-mouth coordination B. Impaired voluntary cough C. Altered level of consciousness D. Unilateral ptosis

Correct Answer is B

Explanation

Choice A reason: Diminished hand-to-mouth coordination is not a finding that requires a referral to speech-language pathology, as it is related to the motor function of the upper extremities. The nurse should refer the client to physical therapy or occupational therapy for this issue.

Choice B reason: Impaired voluntary cough is a finding that requires a referral to speech-language pathology, as it indicates a possible dysfunction of the swallowing mechanism or the vocal cords. The nurse should refer the client to speech-language pathology for a swallowing evaluation and intervention.

Choice C reason: Altered level of consciousness is not a finding that requires a referral to speech-language pathology, as it is related to the neurological function of the brain. The nurse should monitor the client's Glasgow Coma Scale score and report any changes to the provider.

Choice D reason: Unilateral ptosis is not a finding that requires a referral to speech-language pathology, as it is related to the cranial nerve function of the eye. The nurse should assess the client's pupillary response and eye movements and report any abnormalities to the provider.

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A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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