A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Plan of care changes for the upcoming shift
Intracranial pressure readings
Glasgow results
Code status
The Correct Answer is D
Choice A reason: Plan of care changes for the upcoming shift
Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.
Choice B reason: Intracranial pressure readings
Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.
Choice C reason: Glasgow results
The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.
Choice D reason: Code status
Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Obtain a 12-lead ECG
Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.
Choice B reason: Suggest that the client use a salt substitute
Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.
Choice C reason: Advise the client to add citrus juices and bananas to her diet
Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.
Choice D reason: Obtain a blood sample for a serum sodium level
While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.
Correct Answer is ["3"]
Explanation
Step 1: Identify the prescribed dose.
- The prescribed dose is 30 mg.
- Result: 30 mg.
Step 2: Identify the strength of the available tablets.
- The available tablets are 10 mg each.
- Result: 10 mg/tablet.
Step 3: Calculate the number of tablets to administer.
- Number of tablets = (Prescribed dose in mg) ÷ (Strength of available tablets in mg/tablet).
- Number of tablets = 30 mg ÷ 10 mg/tablet.
- Number of tablets = 3 tablets.
- = 3 tablets.
So, the nurse should administer 3 tablets of fluoxetine per dose.
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