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.”.

Answer and Explanation

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%

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Correct Answer is C

Explanation

The correct answer is choice C. Blow into the meter as hard and quickly as possible.

This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can.

This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.

Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.

Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.

Choice D is wrong because recording the average of the readings is not recommended.

You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.

Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.

A. Suggest rinsing his mouth with an alcohol-based mouth wash. B. Instruct the client on the use of esophageal speech. C. Offer the client saltine crackers between meals. D. Provide humidification of the room air.

Correct Answer is D

Explanation

Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.

Choice A is wrong because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.

Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.

Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.

It has nothing to do with saliva flow or dry mouth.

Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.

They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.

Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.

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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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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?