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

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

A. "I'm sure it will work if you just give it a chance." B. "You may take any herbal remedies you bring from home." C. "Would you like me to give you a back massage?" D. "Why do you think pain medication is not going to help you?"

Correct Answer is C

Explanation

If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can oﬀer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.

a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.

b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.

d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first oﬀer non- pharmacological interventions to help relieve the client's pain.

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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 monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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