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 B

Explanation

Before administering enteral feedings via an NG tube, the nurse should check for gastric residual volume to ensure that the client is able to tolerate the feeding. If the residual volume is high, it may indicate delayed gastric emptying and the feeding may need to be delayed or the rate adjusted.

a. Encouraging the client to take sips of water may help maintain hydration, but it is not necessary prior to administering enteral feedings.

c. Flushing the tube with sterile 0.9% sodium chloride irrigation can help maintain patency of the tube, but it is not necessary prior to administering enteral feedings.

d. Encouraging the client to breathe deeply and cough can help clear secretions from the lungs, but it is not necessary prior to administering enteral feedings.

A. Place the base of a vibrating tuning fork on the top of the client's head. B. Count how many seconds a client can hear a tuning fork after it has been struck. C. Place the base of a vibrating tuning fork on the client's mastoid process. D. Move a vibrating tuning fork in front of the client's ear canals one after the other.

Correct Answer is A

Explanation

The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².

Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.

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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 caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

Correct Answer is B

Explanation

A nurse is testing a client for conduction deafness by performing the Weber's test. Which of the following actions should the nurse take when performing this test?

Correct Answer is A

Explanation

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