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NCLEX · Coordinated Care (LPN/LVN Scope)

The nurse receives a client from surgery. During the hand-off report, which piece of information is MOST critical to verify?

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Correct answer

Known allergies — surgical medications, latex, antibiotics, and anaesthetic agents may have been used; if an allergy was not properly documented or communicated, the post-surgical team may unknowingly administer a cross-reactive substance; allergy verification at every hand-off prevents medication errors

  1. A Known allergies — surgical medications, latex, antibiotics, and anaesthetic agents may have been used; if an allergy was not properly documented or communicated, the post-surgical team may unknowingly administer a cross-reactive substance; allergy verification at every hand-off prevents medication errors
  2. B The surgeon's contact number
  3. C The client's room preferences
  4. D The client's insurance information

Why this is the answer

SBAR HAND-OFF REPORT — PRIORITY ELEMENTS:

Situation: What procedure was done, current condition.

Background: Relevant history, reason for surgery.

Assessment: Current vital signs, pain level, assessment findings.

Recommendations: Orders, next steps, urgent concerns.

Critical to verify: ALLERGIES (safety — can't give anything until verified); current medications (what was given in surgery, what is ordered post-op); IV access (locations, condition, current infusions); drains and tubes (type, location, output since surgery); post-op orders (diet, activity, medications, wound care); last vital signs and pain assessment; relevant lab values (glucose, haemoglobin).

Hand-off communication: Standardised hand-off (SBAR or I-PASS) reduces communication errors; read-back of critical values; opportunity to ask questions.

Use of i-pass: Illness severity; Patient summary; Action list; Situation awareness/contingency planning; Synthesis by receiver.

Source: NCLEX-PN Safe Care — Management of Care, Hand-Off Communication Priority

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About this topic: Coordinated Care (LPN/LVN Scope)

Coordinated care questions cover the LPN/LVN scope of practice, working under the RN, continuity of care, referrals, and the legal and ethical responsibilities of the practical nurse. This is one of 12 PN: Coordinated Care questions on coordinated care (lpn/lvn scope), each with a full explanation on a single study page.

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