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 is choice A: A nurse is photocopying their assigned client's diagnostic test results.
Choice A rationale: The charge nurse should intervene because photocopying a client's diagnostic test results can pose a potential breach of confidentiality and privacy. Unless there is a specific and authorized reason, personal health information should not be copied or removed from the client's medical record.
Choice B rationale: An assistive personnel (AP) documenting a client's vital signs on the client's paper-based graphic record is a routine task and does not require intervention by the charge nurse.
Choice C rationale: The unit secretary faxing a client's laboratory results to the provider is a standard practice for sharing necessary health information with the care team. No intervention is required.
Choice D rationale: An RN staying with a client who is reading their requested medical records is appropriate. Clients have the right to access their own medical records, and the nurse's presence can help address any questions or concerns the client might have while reviewing their records.
Correct Answer is D
Explanation
Choice A rationale:
A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.
Choice B rationale:
A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.
Choice C rationale:
A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.
Choice D rationale:
Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.
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