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 belief that the client has a difficult relationship with his son
The steps to follow when providing wound care
The time the client received his last dose of pain medication
The client's preferred time for bathing
The Correct Answer is B
Choice A reason: The belief that the client has a difficult relationship with his son is not relevant for the change-of-shift report. This is a subjective and personal opinion that does not affect the client's care or recovery.
Choice B reason: The steps to follow when providing wound care is relevant for the change-of-shift report. This is an objective and clinical information that ensures the continuity and quality of the client's care.
Choice C reason: The time the client received his last dose of pain medication is not relevant for the change-of-shift report. This is a routine and standard information that can be found in the medication administration record or the electronic health record.
Choice D reason: The client's preferred time for bathing is not relevant for the change-of-shift report. This is a preference and not a priority information that can be communicated later or documented in the care plan.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is at risk of tissue ischemia and necrosis, which are serious complications. However, this is not the highest priority, as the condition is chronic and not acute.
Choice B reason: A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is facing a life-threatening illness and needs emotional and physical support. However, this is not the highest priority, as the client is stable and not experiencing any immediate complications.
Choice C reason: A client who has MRSA and has an axillary temperature of 38°C (101°F) has an infection that can spread to other clients and staff, and needs isolation and antibiotic therapy. However, this is not the highest priority, as the fever is mild and the infection is treatable.
Choice D reason: A client who is postoperative following a laminectomy 12 hr ago and is unable to void has urinary retention, which can lead to bladder distension, pain, infection, and renal damage. This is the highest priority, as the client needs immediate intervention to relieve the obstruction and prevent further complications.
Correct Answer is A
Explanation
Choice A reason: Providing the client with written information in their spoken language is the appropriate action for the nurse to take. This would ensure that the client understands the information and can refer to it later. It would also respect the client's culture and preferences.
Choice B reason: Speaking very slowly during the teaching session is not an appropriate action for the nurse to take. This would not improve the communication or comprehension of the client. It might also be perceived as patronizing or disrespectful by the client.
Choice C reason: Using medical terminology while explaining the medications is not an appropriate action for the nurse to take. This would confuse the client and hinder the learning process. The nurse should use simple and clear language that the client can understand.
Choice D reason: Having the client's family member who is present interpret is not an appropriate action for the nurse to take. This would compromise the accuracy and confidentiality of the information. It might also create a conflict of interest or a bias for the family member. The nurse should use a professional interpreter or a translation device if available.
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