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

Answer and Explanation

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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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.

A. Ileostomy stoma is pink. B. Stoma draining moderate brown liquid stool. C. Client will not look at the stoma. D. Client states they are not interested in learning about stoma care E. Intake: 2,200 mL over the last 24 hr F. Skin surrounding the stoma is reddened and appears iritated G. Urine output: 650 mL over the last 24 hr

Correct Answer is ["F"]

Explanation

f) Skin surrounding the stoma is reddened and appears irritated.

The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.

Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is ["F"]

Explanation

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