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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Wearing gloves when handling the client's bed linens is an incorrect action, as it is not enough to protect the nurse from exposure to the chemotherapy agents. The nurse should wear gloves, gown, and mask when handling any body fluids or items contaminated with body fluids from the client.

Choice B reason: Flushing the client's urine down the toilet twice is a correct action, as it helps to prevent contamination of the environment and other people with the chemotherapy agents. The nurse should also instruct the client and the family to do the same for 48 hours after the chemotherapy administration.

Choice C reason: Disposing of the client's intravenous tubing in a regular trash can is an incorrect action, as it poses a risk of exposure to the chemotherapy agents for the nurse and other staff. The nurse should dispose of the client's intravenous tubing in a biohazard container that is labeled as chemotherapy waste.

Choice D reason: Washing the client's dishes with hot water and soap is an incorrect action, as it is not sufficient to remove the chemotherapy agents from the dishes. The nurse should use disposable dishes and utensils for the client, or wash them separately with bleach and water.

A. A client who reports shortness of breath and left neck and shoulder pain B. A client who has active bleeding from a puncture wound of the left groin area C. A client who has a raised red skin rash on his arms, neck, and face D. A client who reports right-sided flank pain and is diaphoretic

Correct Answer is B

Explanation

Choice A reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac problem, which is a serious condition. However, this client is not the highest priority, as the symptoms are not life-threatening at the moment.

Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority, as this client is at risk of hemorrhage, shock, and infection. The nurse should apply direct pressure to the wound, elevate the leg, and monitor the vital signs.

Choice C reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction, which is a potential emergency. However, this client is not the highest priority, as the symptoms are not severe enough to indicate anaphylaxis.

Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a kidney stone, which is a painful condition. However, this client is not the highest priority, as the symptoms are not life-threatening unless there is an obstruction or infection.

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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?

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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?