A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?
The client's dressing change schedule.
The client's level of consciousness.
The client's vital signs from the previous shift.
The client's occupation.
The Correct Answer is B
Choice A rationale:
The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.
Choice B rationale:
The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.
Choice C rationale:
While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.
Choice D rationale:
The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer isChoice A: Place the client in a dorsal recumbent position for the examination.
Choice A rationale:
The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments.This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.
Choice B rationale:
Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm.The bell is more sensitive to low-frequency sounds like bruits.
Choice C rationale:
The assessment should begin with inspection and auscultation before palpation.Palpation can alter bowel sounds, leading to inaccurate findings.
Choice D rationale:
The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.
Correct Answer is B
Explanation
The correct answer is b. Social services.
Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.
Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.
Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.
Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.
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