Handoff of ongoing care

  • NCLEX-PN
  • Coordinated Care
  • Bow-tie
  • Difficulty 3 of 5

Question

Complete the diagram by choosing the condition the client is most likely experiencing, 2 actions to take and 2 parameters to monitor.

Actions to takeSelect 2

  • Give the report verbally to the receiving nurse✓ Correct
  • Include the report in written form✓ Correct
  • Omit the report if a drain is present✗ Incorrect
  • Leave the incoming nurse to locate all information without a report✗ Incorrect

Condition most likely experiencingSelect 1

  • Transfer of care responsibility✓ Correct
  • A completed discharge from care✗ Incorrect
  • An absence of ongoing nursing care✗ Incorrect
  • A request to initiate a new treatment plan✗ Incorrect

Parameters to monitorSelect 2

  • Drain output✓ Correct
  • Urine output✓ Correct
  • Favorite type of music✗ Incorrect
  • Preferred television program✗ Incorrect

Answer

Actions to take: Give the report verbally to the receiving nurse; Include the report in written form · Condition most likely experiencing: Transfer of care responsibility · Parameters to monitor: Drain output; Urine output

Rationale

A consistent verbal and written exchange helps the receiving nurse continue care. Drain and urine output are relevant information to carry forward when monitoring a client with a drain.

RememberDuring handoff, communicate the information needed for continued monitoring.

Sources

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