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 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.
Correct Answer is A
Explanation
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.
This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.
Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.
The nurse should assess this client first and notify the provider.
Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.
The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.
Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.
The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.
Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.
The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.
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