The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy.

The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining.

Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea.

The last dose was administered at 0700.

The client is currently describing pain at a level 2 on a 0 to 10 pain scale.

The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain.

The last dose was administered at 1000." Which additional information should the PACU nurse report?

Choice A rationale:

Monitoring ETT markings between 22 and 26 cm at the teeth line is essential to ensure proper placement of the endotracheal tube (ETT). This helps confirm that the ETT is positioned correctly in the trachea.

Choice B rationale:

Checking for capillary refill is not a reliable method for verifying the placement of an ETT. It is more indicative of peripheral circulation and not related to airway management.

Choice C rationale:

Obtaining a portable chest x-ray is a crucial step to verify the exact placement of the ETT within the trachea and to rule out potential complications such as pneumothorax.

Choice D rationale:

Assessing for symmetrical chest movement is important because unequal chest rise and fall could indicate an issue with ETT placement or lung function.

Choice E rationale:

Auscultating for bilateral breath sounds is another method to confirm that the ETT is correctly positioned in the trachea and that both lungs are being ventilated adequately.

The correct answer is Choice C: Assign the remainder of medication administration to another PN who is performing treatments.

Choice A rationale: Denying the medication aide's request to leave before all medications are given does not address the issue at hand and could potentially jeopardize patient care. It is important to acknowledge the medication aide's request and find an appropriate solution that ensures patient safety and well-being.

Choice B rationale: Delegating medication administration to unlicensed assistive personnel (UAP) who may not have the necessary training or authorization could lead to medication errors, adverse drug reactions, or other negative outcomes. It is essential to adhere to the scope of practice guidelines and facility policies when assigning tasks to UAPs.

Choice C rationale: Reassigning the medication administration to another PN with the necessary qualifications and training ensures that patients receive their medications in a safe and timely manner. This action aligns with the practical nurse's responsibility to supervise and delegate tasks appropriately, maintaining patient safety and upholding the standards of care.

Choice D rationale: Documenting why medications were not given to each resident is an important aspect of maintaining accurate and comprehensive patient records. However, it does not address the immediate need to administer medications to residents, and it is not a substitute for ensuring that patients receive their prescribed treatments. Documentation should be completed after the appropriate steps have been taken to administer medications or arrange for an alternative solution.