Nokea
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?
Correct Answer: B
Rationale: Transfer documentation ensures continuity of care, focusing on critical, current data for the receiving team. The primary health problem is essential it summarizes why the client's status changed (e.g., respiratory failure, sepsis), guiding ICU interventions. Number of family members who visited is irrelevant to clinical management; it's a social detail, not a priority. Admission vital signs from a week ago are outdated current vitals matter more, especially with a status change. Scheduled dressing changes are useful but secondary to understanding the underlying condition driving the transfer. Identifying the primary issue provides context for the client's deterioration, aligns with handoff standards like SBAR (Situation, Background, Assessment, Recommendation), and ensures the ICU team addresses the root cause immediately. This focus on relevance enhances patient safety, reduces miscommunication, and supports rapid response in a critical setting, making it the most vital piece of transfer information.