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 steps to follow when providing wound care
The client's preferred time for bathing
The belief that the client has a difficult relationship with his son
The Correct Answer is B
Choice A reason: This is not the information that the nurse should include in the change-of-shift report. The time the client received his last dose of pain medication is not relevant to the transfer to the rehabilitation facility. The nurse should document the pain medication administration in the medication record and communicate it to the receiving nurse.
Choice B reason: This is the information that the nurse should include in the change-of-shift report. The steps to follow when providing wound care are important to ensure the continuity and quality of care for the client. The nurse should explain the type, location, and condition of the wound, the dressing materials and frequency, and any signs of infection or complications.
Choice C reason: This is not the information that the nurse should include in the change-of-shift report. The client's preferred time for bathing is not essential to the transfer to the rehabilitation facility. The nurse should respect the client's preferences and routines, but they are not a priority for the report.
Choice D reason: This is not the information that the nurse should include in the change-of-shift report. The belief that the client has a difficult relationship with his son is not based on facts and may be biased or inaccurate. The nurse should avoid making assumptions or judgments about the client's family dynamics and focus on the objective data and the client's needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering IV nitroglycerin to a client who is experiencing chest pain is not an appropriate assignment for the float nurse, as it requires advanced cardiac knowledge and skills that the nurse may not have. The charge nurse should assign this task to a nurse who is experienced in the emergency department.
Choice B reason: Completing a SAD PERSONS assessment scale for a client who has attempted suicide is not an appropriate assignment for the float nurse, as it requires mental health expertise and training that the nurse may not have. The charge nurse should assign this task to a nurse who is qualified in psychiatric nursing.
Choice C reason: Setting up a trauma room for an incoming client who was in a motor-vehicle crash is not an appropriate assignment for the float nurse, as it requires emergency preparedness and competence that the nurse may not have. The charge nurse should assign this task to a nurse who is familiar with the trauma protocols and equipment.
Choice D reason: Performing a urinary catheterization for a client who has experienced a cerebrovascular accident is an appropriate assignment for the float nurse, as it is a basic nursing skill that the nurse should have learned and practiced in the medical-surgical unit. The charge nurse should assign this task to the float nurse as long as the nurse is comfortable and confident with the procedure.
Correct Answer is B
Explanation
Choice A reason: Information regarding organ donation is not part of advance directives, but rather a separate document that the client can sign to indicate their willingness to donate their organs or tissues after death. The nurse should inform the client about the option and process of organ donation, but not include it in the advance directives.
Choice B reason: Instructions regarding treatments the client desires or does not desire is part of advance directives, as it allows the client to express their preferences and values regarding their health care in case they become unable to make decisions for themselves. The nurse should help the client understand the benefits and risks of different treatments and document their choices in the advance directives.
Choice C reason: Information regarding the disposition of the client's body upon death is not part of advance directives, but rather a personal or legal matter that the client can arrange with their family or attorney. The nurse should respect the client's wishes regarding their body after death, but not include it in the advance directives.
Choice D reason: A form with directions for contacting next of kin is not part of advance directives, but rather a routine document that the client can fill out when they are admitted to the facility. The nurse should obtain the client's contact information and emergency contacts, but not include it in the advance directives.
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