A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or. contraindicated for the client.

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

Choice A rationale:

Checking the medical record for prior blood glucose test results is a task that can be delegated to the assistive personnel (AP). It provides relevant information for the nurse to assess the client's current condition. However, it is not the most crucial step in ensuring the safe performance of the blood glucose test.

Choice B rationale:

Asking the client if she has taken her antidiabetic medication today is important, but this task is better suited for the nurse, as it requires accurate communication with the client about their medication history and adherence. Delegating this task to the AP may lead to potential misunderstandings or errors in the information provided.

Choice C rationale:

The nurse should determine if the AP has the necessary skills and competence to perform the blood glucose test. Delegating tasks based on the competency of the staff member ensures the safety and well-being of the client. If the AP is not skilled in performing the test, the nurse should assign the task to someone else or perform the test personally.

Choice D rationale:

The nurse should not directly perform the blood glucose test if it can be safely delegated to the AP. Delegating appropriate tasks to competent staff members allows nurses to focus on more complex aspects of client care and ensures efficient use of resources within the healthcare team.