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 A, C, B, D

Explanation

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

A. Palpate the abdomen B. Administer an antiemetic. C. Oﬀer pain medication. D. Auscultate bowel sounds.

Correct Answer is D

Explanation

A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.

B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.

C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.

D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.

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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

Naxlex Comprehensive Predictor Exams

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A, C, B, D

Explanation

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Correct Answer is D

Explanation

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