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."

"The estimated blood loss was 250 milliliters."

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

"The client is a member of the board of directors."

Answer and Explanation

The Correct Answer is B

A. "The client was intubated without complications.": While this information can be relevant, it is more pertinent to include in the PACU hand-off only if intubation or airway management had ongoing implications. Routine, uncomplicated intubation is less critical than current clinical status and intraoperative events.

B. "The estimated blood loss was 250 milliliters.": Reporting estimated blood loss is essential for continuity of care, as it informs the receiving nurse about the client’s fluid status, potential for anemia, and need for ongoing monitoring or interventions. This is a key safety and clinical detail in the hand-off report.

C. "There was a total of 10 sponges used during the procedure.": While sponge count is important intraoperatively to prevent retained surgical items, it is typically documented in the surgical record and does not usually impact post-anesthesia care unless discrepancies exist.

D. "The client is a member of the board of directors.": Personal information unrelated to the client’s clinical care is not appropriate to include in a hand-off report. The focus should remain on pertinent medical, surgical, and recovery information.

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Correct Answer is D

Explanation

A. Refer the family to a chronic pain support group: While psychosocial support can be beneficial for children with chronic migraines, referral to a support group is not the priority initial action. The first step is to assess and understand the pattern and triggers of the headaches.

B. Request a change in medication from the provider: Medication adjustments may be necessary, but the nurse must first gather objective and subjective data on the child’s pain patterns, frequency, and triggers before advocating for changes in pharmacologic management.

C. Set up an appointment with the school nurse: Collaborating with the school nurse can help manage migraines during school hours, but this action is secondary to assessing the child’s headache history and current management at home.

D. Review the child's electronic pain diary: Reviewing the electronic pain diary provides detailed, chronological information about headache frequency, intensity, triggers, and response to interventions. This assessment is essential for guiding further interventions and is the first action in clinical decision-making according to the nursing process.

A. Prime the tubing with 0.9% sodium chloride. B. Attach a single-line administration set. C. Use tubing that does not have a filter in the drip chamber. D. Use an IV catheter that is at least 24-gauge.

Correct Answer is A

Explanation

A. Prime the tubing with 0.9% sodium chloride: Blood products must be administered with 0.9% sodium chloride to prevent hemolysis. Priming the tubing with saline ensures compatibility and maintains patency, allowing safe and effective transfusion without compromising the integrity of red blood cells.

B. Attach a single-line administration set: Blood transfusions require a specialized Y-type or filtered tubing to reduce the risk of clots, debris, and air embolism. Using a single-line set without a filter could allow microaggregates to enter the circulation.

C. Use tubing that does not have a filter in the drip chamber: A filter is essential for removing clots, debris, and cellular aggregates from the blood product. Administering blood without a filter increases the risk of complications such as emboli and febrile reactions.

D. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for safe transfusion of blood products. A larger-bore catheter, typically 18–20 gauge, is recommended to allow adequate flow and prevent hemolysis or catheter rupture during transfusion.

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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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