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 client's preferred time for bathing

The time the client received his last dose of pain medication

The belief that the client has a difficult relationship with his son

The steps to follow when providing wound care

Answer and Explanation

The Correct Answer is B

A.   The client's preferred time for bathing: While this information may be relevant to the client's care, it is not typically included in a change-of-shift report unless it directly impacts the client's medical condition or care plan.
B.   The time the client received his last dose of pain medication: This information is crucial for ensuring continuity of care and managing the client's pain appropriately during the transfer to the rehabilitation facility.
C.   The belief that the client has a difficult relationship with his son: While psychosocial factors can impact a client's care, this information may not be relevant to the client's immediate medical needs or the transition to the rehabilitation facility.
D.   The steps to follow when providing wound care: While wound care instructions are important, they are typically documented in the client's medical record and may not need to be included in a change-of-shift report unless there are specific wound care concerns that need to be addressed during the transfer.

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Correct Answer is A

Explanation

A. Elevating the head of the client’s bed to 30° before inserting a nasogastric (NG) tube is incorrect. The proper position for NG tube insertion is typically with the client sitting upright at 45–90° to reduce the risk of aspiration and facilitate the passage of the tube through the esophagus. This action requires intervention by the charge nurse to correct the positioning.

B. Maintaining the chest tube collection device below the level of the insertion site when ambulating the client is correct. This positioning prevents backflow of drainage into the pleural space, which could lead to complications such as pneumothorax or infection. No intervention is needed for this action.

C. Assisting the client into a fetal position on their side in preparation for a lumbar puncture is correct. This position helps to widen the spaces between the vertebrae, allowing easier access to the spinal canal for the procedure. This action does not require intervention.

D. Assessing the client’s gag reflex following an esophagogastroduodenoscopy (EGD) is correct. After an EGD, the client’s gag reflex must return before allowing oral intake to prevent aspiration. This action does not require intervention.

A. Observe staff medication administration procedures. B. Require staff to complete a medication administration review module. C. Identify data that should be collected related to medication errors. D. Re-evaluate staff performance in relation to the established standard.

Correct Answer is C

Explanation

A. Observe staff medication administration procedures: While observation can provide valuable insights into workflow and potential areas for improvement, it may not address the underlying causes of medication errors or provide comprehensive data for quality improvement efforts.
B. Require staff to complete a medication administration review module: Education and training are important components of improving medication safety, but they may not be the most
immediate or effective response to addressing an elevated rate of medication errors.

C. Identify data that should be collected related to medication errors: This is the correct answer.

Before implementing interventions to address medication errors, it is important to gather comprehensive data on the types, causes, and frequency of errors. This data will help identify specific areas for improvement and guide the development of targeted interventions.
D. Re-evaluate staff performance in relation to the established standard: While ongoing evaluation of staff performance is important for maintaining quality care, it may not be the most appropriate first step when addressing an elevated rate of medication errors. Gathering data on medication errors and their contributing factors is essential for understanding the root causes of the problem and developing effective solutions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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