A home health nurse is assisting in the care of a client.

Exhibits
Select the 4 findings that indicate an understanding of the reinforced teaching

Amount of time washing hands

Use of cutting board

Defrosting of frozen foods

Leftover storage time in refrigerator

Refrigerator temperature

Time leftovers sit unrefrigerated on countertop

Answer and Explanation

Correct Answer : A,B,C,D

A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.

B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.

C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.

D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth. This aligns with recommended guidelines.

E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.

F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.

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Correct Answer is ["A","B","F"]

Explanation

A. Dietary intake: The client ate toast at 0600 and experienced vomiting. Since general anesthesia is typically used for an appendectomy, recent food intake increases the risk of aspiration and should be reported immediately to the surgical team.

B. Pain level: The client reports increasing pain (now 8/10) with rebound tenderness. This may indicate worsening inflammation or risk of rupture, which requires reassessment and potentially expedited surgical intervention.

C. Blood pressure: The blood pressure of 124/80 mm Hg is within normal limits and does not require follow-up before surgery. It reflects stable hemodynamics.

D. Informed consent: The provider has already obtained informed consent and placed it in the medical record. No further follow-up is needed unless the client withdraws consent or shows signs of confusion.

E. Oxygen saturation: The client's oxygen saturation is 96% on room air, which is acceptable. There are no indications of respiratory compromise that require further intervention preoperatively.

F. Allergies: The client reports allergies to shellfish, latex, and penicillin. These pose serious risks during surgery (e.g., anaphylaxis to latex gloves or antibiotics) and must be addressed in the preoperative checklist to ensure appropriate substitutes are used.

A. An assistive personnel is late for the upcoming shift. B. A client refuses to eat at mealtime. C. A family member is napping in the client's room. D. A client's bed alarm is malfunctioning.

Correct Answer is D

Explanation

A. An assistive personnel is late for the upcoming shift: Tardiness is an issue of staff performance or scheduling rather than client safety, and it should be addressed through administrative or managerial processes. It does not require an incident report unless it directly results in harm or neglect to a client.

B. A client refuses to eat at mealtime: Client refusal to eat is a common occurrence and is managed through nutritional assessments and care planning. While it should be documented in the medical record, it does not constitute an unusual or adverse event that requires an incident report.

C. A family member is napping in the client's room: A family member resting in the room is not an incident unless it interferes with care or violates facility policy. This situation is not associated with client harm or safety risk, so it does not meet the criteria for incident reporting.

D. A client's bed alarm is malfunctioning: A malfunctioning bed alarm is a safety issue, particularly for clients at risk of falls. It represents a potential hazard that could lead to client injury, making it necessary to complete an incident report to document the problem and prompt timely intervention or equipment repair.

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A home health nurse is assisting in the care of a client. Exhibits Select the 4 findings that indicate an understanding of the reinforced teaching

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is scheduled for an appendectomy. Exhibits The nurse is assisting with preparing the client for surgery. Select the 3 findings that require follow-up prior to surgery.

Correct Answer is ["A","B","F"]

Explanation

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about incident reporting. The nurse should identify that it is necessary to complete an incident report for which of the following situations?

Correct Answer is D

Explanation

A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings, the nurse should use which of the following terms?

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A nurse is assisting in the care of a client. Exhibits Complete the following sentence by using the lists of options. At 1000 the nurse enters the client's room. The first action the nurse should take is dropdown followed by dropdown .

A home health nurse is assisting in the care of a client.

Exhibits
Select the 4 findings that indicate an understanding of the reinforced teaching