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 client's preferred time for bathing
The steps to follow when providing wound care
The belief that the client has a difficult relationship with his son
The Correct Answer is C
Choice A Reason:
The time the client received his last dose of pain medication is incorrect. While this information is relevant for ongoing pain management, it may not be as critical for the receiving facility unless there are specific pain management protocols in place that need to be followed.
Choice B Reason:
The client's preferred time for bathing is incorrect. While knowing the client's preferences is important for providing individualized care, the preferred time for bathing may not be immediately pertinent to the client's care upon transfer to the rehabilitation facility.
Choice C Reason:
The steps to follow when providing wound care is correct. This information is essential for the receiving facility to ensure proper wound care continues without interruption. It helps ensure consistency in care and minimizes the risk of complications related to wound healing.
Choice D Reason:
The belief that the client has a difficult relationship with his son is incorrect. While psychosocial information about the client is important for holistic care, it may not be the most crucial information to include in the change-of-shift report for transfer to a rehabilitation facility unless it directly impacts the client's medical care or rehabilitation plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Checking the reading after the other nurse leaves the room is incorrect because it does not address the immediate need for accurate data and doesn't ensure that the initial readings were correct. It's important to act promptly to verify the accuracy of the readings to ensure patient safety.
Choice B Reason:
Documenting a pulse deficit of 16 beats per minute is incorrect. While there seems to be a difference of 16 beats per minute between the apical and radial pulses, it's essential to confirm this discrepancy with further assessment rather than immediately documenting it. Documentation should be based on accurate and verified data.
Choice C Reason:
Report the results of the deficit to the healthcare provider is incorrect. Reporting the results to the healthcare provider without confirming the accuracy of the initial readings may lead to unnecessary alarm or inappropriate interventions. It's important to ensure the data is reliable before escalating to the healthcare provider.
Choice D Reason:
Repeating the assessment to obtain another reading is correct because it allows the nurses to confirm the accuracy of the initial readings and ensure that there is indeed a pulse deficit. This action promotes patient safety by obtaining reliable data for appropriate intervention if needed. It's crucial to rule out any errors or discrepancies in the initial readings before taking further action or reporting to the healthcare provider.
Correct Answer is D
Explanation
Choice A Reason:
White blood cell count (WBC) is incorrect. Melena, which is the passage of black, tarry stools, is typically associated with upper gastrointestinal bleeding rather than an infection. While changes in WBC count might occur in response to infection or inflammation, it is not the primary laboratory test to monitor in response to melena.
Choice B Reason:
Glucose is incorrect.
Glucose monitoring is important for assessing blood sugar levels, particularly in diabetic patients or those at risk of hypoglycemia or hyperglycemia. However, it is not directly related to the presence of melena, which indicates gastrointestinal bleeding.
Choice C Reason:
Blood urea nitrogen (BUN) is incorrect. Blood urea nitrogen (BUN) levels can indicate renal function and hydration status, but they are not specifically related to the presence of melena. Monitoring BUN may be relevant in other clinical contexts, such as assessing kidney function or dehydration, but it's not the primary laboratory test to monitor in response to melena.
Choice D Reason:
Hematocrit is correct. Melena indicates upper gastrointestinal bleeding, which can lead to a significant loss of blood. Monitoring the hematocrit level is crucial in this context because it helps assess the severity of bleeding and guide appropriate interventions such as blood transfusions if necessary. A decrease in hematocrit indicates a decrease in the volume of red blood cells, which reflects blood loss and the need for further evaluation and management.
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