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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["100"]
Explanation
Step 1: Identify the infusion rate in mL/hr.
- The infusion rate is 100 mL/hr.
- = 100 mL/hr.
Step 2: Determine the drop factor for microtubing.
- Microtubing has a drop factor of 60 gtt/mL.
- = 60 gtt/mL.
Step 3: Calculate the drip rate in gtt/min.
- Drip rate (gtt/min) = (Infusion rate in mL/hr) × (Drop factor in gtt/mL) ÷ 60.
- Drip rate (gtt/min) = 100 mL/hr × 60 gtt/mL ÷ 60.
- = 100 gtt/min.
So, the nurse should set the manual IV infusion to deliver 100 gtt/min.
Correct Answer is C
Explanation
Choice A reason:
Pruritus: Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.
Choice B reason:
Swollen gums: Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.
Choice C reason:
Dysphagia: Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.
Choice D reason:
Urinary hesitancy: Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.
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