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 D
Explanation
A. Change IV solution bags every 36 hr: Changing IV solution bags every 36 hours may not align with evidence-based practices aimed at promoting cost-effective care. Instead, guidelines typically recommend changing them based on clinical need or specific protocols, which can help reduce waste and costs.
B. Avoid the delegation of hygiene care to assistive personnel (AP): Delegating hygiene care to assistive personnel is essential for effective team functioning and cost-effective care. Preventing delegation can lead to increased workloads for nursing staff, which may not be the most efficient use of resources.
C. Wear sterile gloves when removing urinary retention catheters: Wearing sterile gloves when removing urinary retention catheters is not necessary; clean gloves are sufficient for this procedure. Promoting correct practices that align with guidelines can help reduce costs associated with unnecessary supplies.
D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions: Educating staff on the correct use of PPE is vital for preventing infection, reducing the spread of illness, and minimizing healthcare costs associated with complications. Proper training ensures that resources are used effectively, promoting both safety and cost-effective care.
Correct Answer is B
Explanation
A. Notify the provider: While it is essential to inform the provider about the medication error, the immediate priority is to assess the client's condition first to determine if any adverse effects have occurred. The provider can be notified after ensuring the client is stable.
B. Check the condition of the client: The first action the nurse should take is to assess the client's condition. This includes monitoring for any immediate adverse effects or reactions related to the wrong medication administered. Ensuring the client's safety is the top priority in this situation.
C. Report the occurrence to the unit manager: Reporting the error to the unit manager is an important step in the process but should be done after assessing the client's condition. The immediate focus must be on the client's well-being before addressing administrative aspects of the error.
D. Complete an incident report: Completing an incident report is necessary for documenting the error and ensuring quality improvement measures, but it is not the first action. The nurse must first prioritize the assessment and safety of the client.
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