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 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

The client's preferred time for bathing

Answer and Explanation

The Correct Answer is A

- A) Knowing the time the client received his last dose of pain medication is crucial for continuity of care, ensuring that the client receives their next dose on time and pain management is consistent.
- B) Personal beliefs about the client's relationships are not relevant to the medical care and should remain confidential unless it directly impacts the care plan.
- C) While important, the detailed steps for wound care will be included in the client's care plan and are not typically communicated during a change-of-shift report unless there is a change or an issue.
- D) The client's preferred time for bathing is a part of personal care preferences and, while important for client comfort, is not critical information for a change-of-shift report unless it affects immediate care needs.

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Correct Answer is B

Explanation

a. Recommending the AP come back later may delay necessary documentation and disrupt workflow.
b. Logging out so the AP can log in to document the vital signs ensures accurate and timely documentation without compromising security or privacy.
c. Offering to chart the vital signs for the AP may blur roles and responsibilities, as charting should be done by the individual who performed the assessment.
d. Allowing the AP to document vital signs prior to logging out may violate policies regarding unauthorized

A. “A nurse can disclose information to a family member with the client’s permission” B. “A nurse is responsible for informing clients about treatment options” C. "A nurse can apply restraints on a PRN basis” D. “A nurse can administer medications without consent to a client as part of a research study”

Correct Answer is A

Explanation

- Rationale for A: Client confidentiality is a fundamental part of nursing ethics and legal practice. A nurse may disclose information to a family member only if the client has given permission, ensuring respect for the client's autonomy and privacy.
- Rationale for B: While it is true that nurses play a crucial role in patient education, the primary responsibility for informing clients about treatment options lies with the attending physician or healthcare provider.
- Rationale for C: The use of restraints is highly regulated in healthcare settings. Restraints can only be applied based on specific criteria and orders that are not on a PRN (as needed) basis, to protect the safety and rights of the client.
- Rationale for D: Administering medications without consent, even as part of a research study, is unethical and illegal unless specific and stringent consent procedures are followed, which include informed consent and approval by an institutional review board (IRB).

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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

A nurse has just completed assessment charting on the electronic record for an assigned client. As assistive personnel (AP) who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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