A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

"The client was intubated without complications."

"The estimated blood loss was 250 milliliters."

"There was a total of 10 sponges used during the procedure."

"The client is a member of the board of directors."

Answer and Explanation

The Correct Answer is B

A. "The client was intubated without complications.": While this information can be relevant, it is more pertinent to include in the PACU hand-off only if intubation or airway management had ongoing implications. Routine, uncomplicated intubation is less critical than current clinical status and intraoperative events.

B. "The estimated blood loss was 250 milliliters.": Reporting estimated blood loss is essential for continuity of care, as it informs the receiving nurse about the client’s fluid status, potential for anemia, and need for ongoing monitoring or interventions. This is a key safety and clinical detail in the hand-off report.

C. "There was a total of 10 sponges used during the procedure.": While sponge count is important intraoperatively to prevent retained surgical items, it is typically documented in the surgical record and does not usually impact post-anesthesia care unless discrepancies exist.

D. "The client is a member of the board of directors.": Personal information unrelated to the client’s clinical care is not appropriate to include in a hand-off report. The focus should remain on pertinent medical, surgical, and recovery information.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Teach the client to keep the cast clean and dry: While client education is important, it is not the immediate priority. Ensuring neurovascular integrity takes precedence over teaching after cast application.

B. Palpate the pulse distal to the cast: Assessing circulation, sensation, and movement distal to the cast is the first action to identify potential complications such as compartment syndrome or impaired perfusion. Early detection of neurovascular compromise is critical to prevent tissue damage.

C. Position the casted extremity on a pillow: Elevating the extremity helps reduce edema and discomfort, but it is secondary to assessing distal circulation to ensure the extremity is receiving adequate blood flow.

D. Place an ice pack over the cast: Applying ice can decrease swelling and pain; however, neurovascular assessment must be completed first to ensure that cold therapy does not mask or worsen compromised circulation.

A. "You did the right thing by bringing your partner in for treatment." B. "Why do you think your partner's symptoms are progressing so quickly?" C. "Can you talk about what was happening with your partner at home?" D. "You should make sure your partner takes the prescribed medication."

Correct Answer is C

Explanation

A. "You did the right thing by bringing your partner in for treatment.": While supportive, this statement provides reassurance rather than facilitating expression of feelings or exploration of the partner’s experience. Therapeutic communication focuses on encouraging dialogue and understanding.

B. "Why do you think your partner's symptoms are progressing so quickly?": Asking “why” can come across as judgmental and may make the partner defensive. It does not encourage open discussion about feelings or experiences, which is central to therapeutic interaction.

C. "Can you talk about what was happening with your partner at home?": This open-ended statement encourages the partner to describe observations and feelings, promoting emotional expression and building rapport. It facilitates assessment of the home environment and caregiving challenges, which is essential in planning support.

D. "You should make sure your partner takes the prescribed medication.": This directive focuses on compliance rather than exploring the partner’s emotional state or providing support. It does not address the partner’s immediate feelings of overwhelm and uncertainty.

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A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report?

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