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 middle adult client who leaves the facility against medical advice does not require the involvement of the ethics committee. The nurse should document the client's decision, inform the provider, and provide discharge instructions.
Choice B reason: A young adult client who is participating in a medical research study does not require the involvement of the ethics committee. The nurse should ensure that the client has given informed consent and is aware of the potential risks and benefits of the study.
Choice C reason: An older adult client who has advance directives on file does not require the involvement of the ethics committee. The nurse should respect the client's wishes and follow the directives in case of a life-threatening situation.
Choice D reason: An adolescent client whose parents refuse a blood transfusion for religious reasons requires the involvement of the ethics committee. The nurse should consult the ethics committee to help resolve the conflict between the parents' beliefs and the client's best interests. The ethics committee can also provide guidance on the legal and ethical implications of the situation.
Correct Answer is C
Explanation
Choice A reason: Report of photophobia is a common finding in clients who have meningitis, as the inflammation of the meninges causes sensitivity to light. However, this is not an urgent finding that requires immediate reporting to the provider.
Choice B reason: Increased temperature is a common finding in clients who have meningitis, as the infection causes fever and systemic inflammation. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is very high or accompanied by other signs of sepsis.
Choice C reason: Decreased level of consciousness is an urgent finding in clients who have meningitis, as it indicates increased intracranial pressure, cerebral edema, or brain herniation. These are life-threatening complications that require immediate intervention and treatment.
Choice D reason: Generalized rash over trunk is a common finding in clients who have meningococcal meningitis, as the bacteria cause petechiae and purpura on the skin. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is extensive or associated with bleeding or shock.
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