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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Rationale:
• Encourage the client to turn from side to side: Epidural anesthesia can cause hypotension and decreased uteroplacental perfusion due to sympathetic blockade. Frequent position changes help promote venous return, enhance circulation, and optimize fetal oxygenation during active labor.
• Assist the client with ambulation: Epidural anesthesia causes motor and sensory block in the lower extremities. The client will likely have reduced strength and sensation in her legs, making walking extremely dangerous due to the high risk of falls.
• Assess for urinary retention: Epidural anesthesia reduces bladder sensation and the urge to void, increasing the risk of urinary retention. A distended bladder can interfere with fetal descent and labor progress, making ongoing assessment necessary.
• Inform the client to expect drowsiness: Epidurals are local/regional anesthetics, not systemic sedatives. While the client may feel relaxed because the pain has subsided, drowsiness is not an expected side effect of an epidural. If a patient becomes drowsy or lethargic, it could indicate a complication like systemic toxicity or a profound drop in blood pressure.
• Monitor for elevated temperature: Epidural anesthesia is associated with an increased risk of maternal fever. Ongoing temperature monitoring helps identify infection or epidural-related hyperthermia early to protect both the client and fetus.
Correct Answer is A
Explanation
A. "This test should be performed after your baby is 24 hours old.": Newborn genetic screening is ideally performed after 24 hours of life to ensure accurate detection of metabolic and endocrine disorders. Performing the test too early can result in false-negative results due to insufficient accumulation of metabolites in the blood.
B. "A nurse will draw blood from your baby's inner elbow.": Newborn screening is typically performed via a heel stick, not from the inner elbow. The lateral or plantar aspect of the heel provides safe access to capillary blood for accurate testing.
C. "Your baby will be given 2 ounces of water to drink prior to the test.": Newborns are not given water prior to screening. Water administration is unnecessary and could be harmful, as infants should receive breast milk or formula to meet hydration needs.
D. "This test will be repeated when your baby is 2 months old.": While some repeat testing may occur if initial results are inconclusive, routine newborn genetic screening is performed once after 24 hours of life, not automatically repeated at 2 months.
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