247SimpleTests
NCLEX · General

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

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 The client's room preferences
  2. B 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
  3. C The client's insurance information
  4. D The surgeon's contact number

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

Practice more questions

This question is from our NCLEX Practice Tests practice test. Take the full practice test to test your knowledge across all General and other topics.

Take the PN: Coordinated Care practice test →

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

Related questions

General

The LPN receives a telephone order from a physician. What is the correct procedure?

 General

Which task can the LPN safely delegate to an unlicensed assistive personnel (UAP)?

 General

A client refuses a procedure that their physician believes is necessary. The nurse's role is to:

 General

A client's medical record contains an advance directive stating 'DNR/DNI — do not resuscitate, do not intubate.' The client is found unresponsive on the unit. What should the nurse do?

State-specific guides

Need information for your state? Our state guides cover local requirements, fees, and what to expect on exam day.

California Texas Florida New York Pennsylvania Illinois Ohio Georgia

Recommended study materials

Study guide

Saunders Comprehensive Review for NCLEX-RN 9th Ed. (Elsevier)

The gold standard for NCLEX-RN prep: 5,200+ practice questions, content review, test-taking strategy.

Check Price → Study guide

NCLEX-PN Prep Plus 2023 (Kaplan)

Targeted NCLEX-PN content review with hundreds of practice questions and video explanations.

Check Price → Study guide

Prioritization, Delegation & Assignment (Elsevier)

The leading resource for NCLEX questions on prioritization, delegation, and management of care.

Check Price →

As an Amazon Associate, CJ Affiliate, and AWIN publisher we earn from qualifying purchases. Links above are affiliate links. Full disclosure →