A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-off report?
Time of the client's last bath
Effectiveness of the last dose of pain medication
Number of family members who have visited
Frequency of previous vital sign measurement
The Correct Answer is B
The correct answer is that the nurse should include information about the effectiveness of the last dose of pain medication in the hand-off report when transferring a client to a long-term care facility. This information is important for the receiving facility to continue managing the client's pain effectively.
Options a, c and d are not essential information to include in the hand-off report. The time of the client's last bath, the number of family members who have visited and the frequency of previous vital sign measurement are not critical for ensuring continuity of care during the transfer.
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Related Questions
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.
Correct Answer is A
Explanation
When caring for a client who has a tracheostomy, the nurse should secure the tracheostomy ties to allow one finger to fit snugly underneath. This helps ensure that the tracheostomy tube is secure and prevents accidental dislodgement.
b) A cotton tip applicator should not be used to clean inside the inner cannula as it can leave fibers behind
and increase the risk of infection.
c) The skin around the stoma should be cleansed with sterile saline, not normal saline, to reduce the risk of infection.
d) The outer cannula should not be soaked in warm, soapy tap water as this can introduce bacteria and increase the risk of infection.
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