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.”
“There was a total of 10 sponges used during the procedure.”
“The estimated blood loss was 250 milliliters.”
“The client is a member of the board of directors.”.
The Correct Answer is C
This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.
Choice A is wrong because “The client was intubated without complications.” is not relevant for the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.
Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent for the postoperative care of the patient.
The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.
Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.
This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.
A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems.
A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.
Some normal ranges that may be useful for postoperative care are:
- Blood pressure: 90/60 mmHg to 120/80 mmHg
- Pulse: 60 to 100 beats/min
- Respiratory rate: 12 to 20 breaths/min
- Oxygen saturation: 95% to 100%
- Temperature: 36°C to 37.5°C
- Hemoglobin: 12 to 18 g/dL
- Hematocrit: 36% to 54%
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Administering potassium via IV bolus is an example of malpractice in nursing.
This is because potassium is a medication that can cause cardiac arrest if given too quickly or in high doses. A nurse who administers potassium via IV bolus is not providing the standard of care that a similarly trained nurse would have offered under the same circumstances.
This could result in harm or death to the patient.
Choice A is wrong because placing a yellow bracelet on a client who is at risk for falls is not malpractice, but rather a safety measure.
A yellow bracelet indicates that the client needs assistance with mobility and should not be left alone. This is a common practice in many health care facilities to prevent falls and injuries.
Choice B is wrong because leaving a nasogastric tube clamped after administering oral medication is not malpractice, but rather a mistake.
A nasogastric tube is a tube that goes through the nose and into the stomach to deliver nutrition or medication.
It should be unclamped after giving oral medication to allow the medication to enter the stomach and prevent reflux or aspiration. However, this error does not rise to the level of malpractice unless it causes harm to the patient, such as vomiting, choking, or infection.
Choice D is wrong because documenting communication with a provider in the progress notes of the client’s medical record is not malpractice, but rather a good practice. A nurse
Correct Answer is D
Explanation
Answer and explanation.
The correct answer is choice D. Herpes zoster is a contraindication for receiving acupuncture treatment because it is an infectious skin disorder that can be transmitted by needles or contact with the affected area. Acupuncture should not be performed on areas of skin that are inflamed, ulcerated, or have sensory deficit.
Choice A is wrong because hypertension is not a contraindication for acupuncture. However, some caution is advised when needling points that may lower blood pressure, such as LI 4, LI 11, ST 36, and SP 6.
Choice B is wrong because hypothyroidism is not a contraindication for acupuncture. In fact, some studies suggest that acupuncture may have beneficial effects on thyroid function and symptoms of hypothyroidism.
Choice C is wrong because obesity is not a contraindication for acupuncture.
Acupuncture may help with weight loss by regulating appetite, metabolism, and hormones.
Some of the absolute contraindications for acupuncture include pregnancy (especially certain points that may induce labor or abortion), medical and surgical emergencies, malignant tumors, bleeding disorders, and use of a demand pacemaker. Some of the relative contraindications include drug or alcohol intoxication, lack of consent, immune deficiency, abnormal heart valves, and fear of needles.
Normal ranges for blood pressure are 120/80 mmHg or lower for systolic and diastolic pressure respectively.
Normal ranges for thyroid-stimulating hormone (TSH) are 0.4 to 4.0 mIU/L.
Normal ranges for body mass index (BMI) are 18.5 to 24.9 kg/m2.
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