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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?

A.

“The client was intubated without complications.”

B.

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

C.

“The estimated blood loss was 250 milliliters.”

D.

“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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Related Questions

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale:

  • Acknowledges the client's feelings:It's important for the nurse to validate the client's concerns and let them know that it's understandable to feel nervous or uncertain about ECT.
  • Provides information about the treatment:The nurse can offer information about the potential benefits of ECT,but it's important not to pressure the client or make them feel like they have to go through with it.
  • Reassures the client of their right to change their mind:This is a crucial aspect of informed consent.The client has the right to withdraw their consent at any time,even after signing the consent form.

Choice B rationale:

  • Places undue pressure on the client:This response implies that the doctor knows what's best for the client and that the client should go through with the treatment even if they have doubts.This can undermine the client's autonomy and decision-making ability.

Choice C rationale:

  • May minimize the client's concerns:While rescheduling the treatment is an option,it's important to explore the client's concerns more thoroughly before suggesting this.It's possible that the client has valid reasons for not wanting to go through with ECT,and these reasons should be addressed.

Choice D rationale:

  • Is disrespectful of the client's autonomy:This response suggests that the client is obligated to go through with the treatment simply because they signed a consent form.This ignores the fact that people can change their minds and that consent is an ongoing process.

Correct Answer is D

Explanation

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

  • Moving both crutches with the stronger leg forward first is incorrect for a three-point gait.This describes a two-point gait,which is used when a client can bear weight on both legs.In a three-point gait,the client bears weight on the unaffected leg and the crutches,not the stronger leg.
  • This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

  • Supporting his body weight while leaning on the axillary crutch pads is also incorrect.This can lead to nerve damage in the armpits and should be avoided.
  • The weight should be distributed through the hands and wrists,not the armpits.

Choice C rationale:

  • Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous.The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

  • Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait.This allows for proper weight distribution,balance,and control of the crutches.
  • It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

  • Weight is borne on the unaffected leg and the crutches,not the affected leg.
  • The crutches and the unaffected leg move forward together,followed by the affected leg.
  • The client should look ahead,not down at their feet.
  • The client should take small,even steps.
  • The client should rest as needed.

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