A nurse in an emergency department is preparing change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report? (Select all that apply.)
The client has a do-not-resuscitate (DNR) prescription.
The client has a continuous IV of lactated Ringer's.
The client was straight catheterized for 350 mL 2 hr ago.
The client has Medicare insurance.
The client lives in a one-story home.
Correct Answer : A,B,C
A. The client has a do-not-resuscitate (DNR) prescription: Including the client’s code status is essential for ensuring that the receiving medical-surgical team follows the appropriate resuscitation plan. This information directly impacts emergency decision-making and aligns with the client's wishes.
B. The client has a continuous IV of lactated Ringer’s: Reporting active IV fluids is necessary for continuity of care, as it affects fluid balance, medication administration, and overall treatment planning. The receiving nurse must be aware of the infusion to monitor for effectiveness and complications.
C. The client was straight catheterized for 350 mL 2 hr ago: Details about recent procedures, such as urinary catheterization, are relevant to ongoing assessment and care. Monitoring urinary output helps evaluate kidney function and fluid status, making it crucial information for the next shift.
D. The client has Medicare insurance: Insurance details are important for administrative and billing purposes but do not directly impact immediate patient care. This information is typically managed by case management or the hospital’s financial services.
E. The client lives in a one-story home: While discharge planning may involve assessing home arrangements, this detail is not immediately necessary for a shift report. Relevant home considerations should be discussed later when planning for discharge and follow-up care.
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Related Questions
Correct Answer is A
Explanation
A. A client awaiting a screening colonoscopy later that day: This client is appropriate for early discharge. As the procedure is non-invasive and not urgent, the client can be discharged and return for the scheduled screening without compromising their health. This decision allows for the efficient use of hospital resources following a mass casualty event.
B. A client whose discharge was cancelled the prior day because they developed respiratory distress: Recommending discharge for this client is not advisable, as their recent respiratory distress indicates ongoing health issues that require monitoring and care. Early discharge could jeopardize their safety and recovery.
C. A client who is 6 hr postoperative following an open cholecystectomy: This client is not a suitable candidate for early discharge. Postoperative patients typically require observation and care to monitor for complications, such as infection or bleeding, in the hours following surgery. Early discharge could put this client's recovery at risk.
D. A client who is prescribed gastric lavage treatments to treat acute aspirin toxicity: This client should not be recommended for early discharge, as they require ongoing treatment and monitoring for aspirin toxicity. Discharging this client prematurely could lead to serious health complications and does not ensure their safety and well-being.
Correct Answer is D
Explanation
A. Giving a glycerin suppository to a client for constipation: Medication administration, including rectal suppositories, requires assessment of bowel function, knowledge of contraindications, and evaluation of effectiveness, which fall under the responsibilities of a licensed nurse.
B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache: Assessing a client’s response to medication requires critical thinking, monitoring for adverse effects, and determining if additional interventions are needed, which are nursing responsibilities that cannot be assigned to assistive personnel.
C. Discussing dietary changes with a client who has a prescription for a gluten-free diet: Providing dietary education involves assessing the client’s current knowledge, identifying nutritional risks, and ensuring understanding of food choices, which requires professional nursing judgment or a consultation with a dietitian.
D. Measuring hourly urinary output for a client who is postoperative: Recording urinary output involves a simple measurement process that does not require clinical decision-making. Assistive personnel can accurately collect and document this data, allowing nurses to focus on interpretation and intervention if necessary.
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