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    Ati rn comprehensive predictor 2023 retake proctored exam

    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?

    Explanation & Rationale

    Rationale: A. "The client is a member of the board of directors.": Personal or non-clinical information such as the client’s status or occupation is irrelevant to care delivery and violates confidentiality principles unless directly related to medical decision-making or care needs. B. "The client was intubated without complications.": While this may be a useful detail in some cases, it is not as clinically relevant as reporting measurable data like blood loss. Intubation is standard for many surgeries, and if no complications occurred, it may not impact ongoing care. C. "The estimated blood loss was 250 milliliters.": Estimated blood loss is a critical piece of information that affects postoperative care decisions, such as fluid replacement, monitoring for hypovolemia, and vital sign trends. It is an essential component of the PACU-to-floor hand-off. D. "There was a total of 10 sponges used during the procedure.": Sponge counts are important intraoperatively to ensure none are retained, but this detail is primarily documented in surgical records. It is not routinely included in hand-off reports unless a count discrepancy occurred.

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