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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Correct Answer is D
Explanation
Choice A reason: Respecting the client's decision and informing the provider is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice B reason: Explaining the benefits and risks of the procedure is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice C reason: Suggesting alternative treatments for the condition is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice D reason: Assessing the client's understanding of the consequences of uterine prolapse and the need for surgery is the first and most appropriate action that the nurse should take. The nurse should determine the client's knowledge, beliefs, and preferences regarding the condition and the surgery, and address any gaps, misconceptions, or concerns. The nurse should also respect the client's autonomy and right to make informed decisions about their health care.
Correct Answer is C
Explanation
Choice A reason: A mask is not sufficient to protect against airborne pathogens, such as the measles virus. A mask only filters out large droplets, but not the small particles that can remain suspended in the air. A mask should be worn when caring for a client who requires droplet precautions, such as influenza or pertussis.
Choice B reason: A client who has varicella should be placed in a negative pressure room, not a positive pressure room. A negative pressure room prevents the contaminated air from escaping the room and infecting others. A positive pressure room does the opposite: it prevents the outside air from entering the room and contaminating the client. A positive pressure room is used for clients who require protective isolation, such as those who are immunocompromised.
Choice C reason: A respirator should be worn when entering the client's room who has the measles. A respirator is a special type of mask that filters out both large and small particles, and provides a tight seal around the face. A respirator is required for clients who require airborne precautions, such as tuberculosis, varicella, or measles.
Choice D reason: A gown and gloves should be worn when providing direct care to the client who has the measles, but they are not specific to airborne precautions. A gown and gloves are part of standard precautions, which apply to all clients regardless of their diagnosis or infection status. A gown and gloves protect the nurse from contact with the client's blood, body fluids, secretions, and excretions.
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