A nurse is assessing a child who has bacterial pneumonia.
Which of the following manifestations should the nurse expect?

The correct answer is:

Choice C: Determine the medical needs of incoming clients through the emergency department.

Here's a breakdown of the rationale for each choice:

Choice A rationale: While calling in additional staff might be helpful in the long run, during the initial surge of patients in a mass casualty event, the Emergency Department (ED) will be the primary area receiving and triaging patients. The medical-surgical unit will likely receive overflow patients after initial stabilization in the ED.

Choice B rationale: This is not a primary responsibility for a nurse on a medical-surgical unit during a mass casualty event. Communication with the media is usually handled by designated public relations personnel.

Choice C rationale: This is the most crucial action for a nurse in this situation. Triaging patients based on the severity of their injuries and prioritizing care is essential in a mass casualty scenario. Nurses will be instrumental in assessing incoming patients relayed from the ED to determine their medical needs and allocate resources accordingly.

Choice D rationale: Discharging patients is not a priority during the initial influx of casualties. The focus is on receiving, stabilizing, and treating the most critically injured patients. Discharges would likely happen after the initial surge subsides.

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 to 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 to 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%