A home health nurse is assisting in the care of a client.

Exhibits
Select the 4 findings that indicate an understanding of the reinforced teaching

Amount of time washing hands

Use of cutting board

Defrosting of frozen foods

Leftover storage time in refrigerator

Refrigerator temperature

Time leftovers sit unrefrigerated on countertop

Answer and Explanation

Correct Answer : A,B,C,D

A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.

B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.

C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.

D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth. This aligns with recommended guidelines.

E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.

F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.

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Correct Answer is A

Explanation

A. "He is allergic to sulfa." Communicating a client’s allergies during transfer is critical to ensure patient safety and prevent adverse reactions. This information directly impacts medication administration and care planning on the receiving unit, making it essential to include in the transfer report.

B. "His partner has been visiting." While family involvement can be helpful, details about visitors are generally less urgent and not typically necessary in a transfer report unless they directly affect the client’s care or safety.

C. "He appears anxious about the transfer." Emotional status is important but is secondary to clinical information. If anxiety significantly affects the client’s care or safety, it might be mentioned, but it is not a priority in a transfer report focused on immediate clinical needs.

D. "He is voiding adequately." Although voiding status is relevant to some clients’ care, it is less critical than allergy information unless the client has a specific condition affecting urinary function that requires close monitoring. The allergy detail remains a higher priority in transfer communication.

A. WBC count B. Pain C. Abdominal findings D. Blood type E. Client's request for information F. Blood pressure G. Platelet count H. Oxygen saturation I. Client's PO intake J. Capillary refill

Correct Answer is ["B","E","F","H","I"]

Explanation

A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.

B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.

C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.

D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.

E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.

F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.

G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.

H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.

I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.

J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.

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A home health nurse is assisting in the care of a client. Exhibits Select the 4 findings that indicate an understanding of the reinforced teaching

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transferring a client to another unit. Which of the following statements should the nurse include in the transfer report?

Correct Answer is A

Explanation

A nurse in an outpatient surgical center is assisting in the care of a client. Exhibits Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report to the provider.

Correct Answer is ["B","E","F","H","I"]

Explanation

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A home health nurse is assisting in the care of a client.

Exhibits
Select the 4 findings that indicate an understanding of the reinforced teaching