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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?
- A. The client's preferred time for bathing
- B. The belief that the client has a difficult relationship with his son
- C. The time the client received his last dose of pain medication
- D. The steps to follow when providing wound care
Correct Answer: C
Rationale: The correct answer is C: The time the client received his last dose of pain medication. This information is crucial for ensuring continuity of care and preventing medication errors. It helps the rehabilitation facility staff know when the next dose is due and if any additional pain relief is needed.
A: The client's preferred time for bathing is important for comfort but not as critical as pain medication timing in a transfer report.
B: The belief about the client's relationship with his son is not relevant to the client's immediate care needs during transfer.
D: The steps for wound care are important but should be included in a separate document or care plan, not necessarily in a brief change-of-shift report.
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A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?
- A. Candidiasis
- B. Gonorrhea
- C. Human papillomavirus
- D. Trichomoniasis
Correct Answer: B
Rationale: Gonorrhea is a reportable STI due to its serious long-term health impacts and public health implications, requiring notification to track and control spread.
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy?
- A. Implementing a client's plan of care based upon nursing goals
- B. Obtaining an interpreter for a client who speaks a different language than the nurse
- C. Documenting a client's refusal to take a prescribed medication
- D. Initiating IV access on a client who has dementia while he is sleeping
- E. Providing written information to a client regarding palliative care
Correct Answer: B,C,E
Rationale: The correct scenarios for client advocacy are B: Obtaining an interpreter for a client who speaks a different language than the nurse, C: Documenting a client's refusal to take a prescribed medication, and E: Providing written information to a client regarding palliative care.
B is correct as it ensures effective communication, promoting the client's understanding and autonomy. C is essential for respecting the client's right to make decisions about their care. E demonstrates advocacy by empowering the client with information about their care options.
A is incorrect as it focuses on the nurse's goals rather than the client's needs. D is inappropriate as it violates the client's rights by performing a procedure without consent.
In summary, client advocacy involves respecting autonomy, ensuring effective communication, and providing information to empower the client in decision-making.
A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
- A. State nurse practice act
- B. ANA Standards of Practice
- C. ANA Code of Ethics
- D. Institute of Medicine
Correct Answer: A
Rationale: The correct answer is A: State nurse practice act. The state nurse practice act outlines the scope of practice for nurses within a specific state, including the tasks they can perform. Removing chest tubes is a clinical procedure that falls within the scope of nursing practice. Consulting the state nurse practice act ensures that nurses are adhering to the legal and regulatory standards when performing such procedures.
B: ANA Standards of Practice focuses on the general standards of nursing practice but may not provide specific guidance on chest tube removal.
C: ANA Code of Ethics pertains to ethical principles in nursing and does not provide specific guidelines for clinical procedures like chest tube removal.
D: Institute of Medicine focuses on healthcare quality and safety but does not provide specific guidance on nursing procedures.
Therefore, the state nurse practice act is the most appropriate resource for the nurse to consult in planning for the policy on chest tube removal.
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
- A. Uses a sterile-gloved hand to adjust the back of the sterile gown
- B. Uses sterile forceps to pack sterile gauze into the wound
- C. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
- D. Sets up the sterile field 30 min prior to performing the dressing change
Correct Answer: B
Rationale: Using sterile forceps to pack gauze maintains sterility, reducing infection risk, unlike actions that breach sterile field integrity.