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

An alternating pressure mattress can help prevent skin breakdown in a client who is immobile by redistributing pressure and reducing the risk of pressure ulcers. This is an appropriate action for the nurse to include in the plan of care for a client who is immobile and has urinary incontinence.

a. An indwelling urinary catheter can increase the risk of infection and should only be used when other methods of managing urinary incontinence are not eﬀective.

c. Cornstarch can absorb moisture and help keep the skin dry, but it is not recommended for use on broken skin or in areas where there is a risk of fungal infection.

d. Repositioning the client every 4 hours may not be frequent enough to prevent skin breakdown. The client should be repositioned at least every 2 hours to reduce the risk of pressure ulcers.

A. Rub his hands together to cause friction for at least 10 seconds. B. Turn oﬀ the faucet with a clean, dry paper towel. C. Dry his hands by working from the forearms down to the fingertips. D. Keep his hands above elbow level when washing.

Correct Answer is B

Explanation

The correct answer is that the nurse should turn oﬀ the faucet with a clean, dry paper towel when performing hand hygiene at the beginning of his shift. This helps to prevent recontamination of the hands by touching the faucet with clean hands.

Options a, c and d are not correct actions for performing hand hygiene. Rubbing hands together to cause friction for at least 10 seconds, drying hands by working from the forearms down to the fingertips and keeping hands above elbow level when washing are not recommended practices for hand hygiene.

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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 planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is performing hand hygiene at the beginning of his shift. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

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