A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

The type of transmission-based precautions in place.

The times for routine vital sign measurements.

The client's background health history.

The number of visitors the client had during the shift.

Answer and Explanation

The Correct Answer is A

When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staﬀ. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.

The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.

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Correct Answer is D

Explanation

The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is a standard procedure for the safe handling and documentation of controlled substances.

a. The nurse should report any discrepancy in the count total of the controlled substance before administration, not after.

b. The wasted portion of the controlled substance should be disposed of according to facility policy, which may not involve placing it in a sharps container.

c. The count total of the controlled substance should be verified before removing the amount needed, not after.

A. Use a cuﬀ with a width that is about 60% of the client's arm circumference. B. Apply the cuﬀ above the client's antecubital fossa. C. Have the client sit with his arm resting above the level of his heart. D. Release the pressure on the client's arm 5 to 6 mm per second.

Correct Answer is A

Explanation

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

Nursing Test Bank

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