A nurse is giving 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?
Glasgow results
Intracranial pressure readings
Code status
Plan of care changes for upcoming shift
The Correct Answer is B
A. Glasgow results: This information would typically be included in the "Assessment" section of SBAR, as it relates to the current status of the client.
B. Intracranial pressure readings: This information is appropriate for the "Background" segment of SBAR as it provides relevant context about the client's condition that could impact the plan of care.
C. Code status: This information should be included in the "Background" section if it is relevant to the client's overall care and treatment plan, but it is not specific to the immediate context of the traumatic brain injury.
D. Plan of care changes for upcoming shift: This information belongs in the "Recommendation" or "Plan" section of SBAR, as it involves the actions or changes planned for the client’s care during the upcoming shift.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["56"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) Drop factor (gtt/mL)
First, calculate the total time in minutes:
- 3 hours 60 minutes/hour = 180 minutes
Then, calculate the volume per minute:
- 500 mL / 180 minutes = 2.78 mL/min
Finally, multiply the volume per minute by the drop factor:
- 2.78 mL/min 20 gtt/mL = 55.6 gtt/min
- Rounded off= 56gtt/min
Correct Answer is B
Explanation
A. Identifying the client by name when making a referral for home health services: This action is generally permissible if done in the context of necessary care coordination and with appropriate privacy measures in place.
B. Reporting laboratory findings to a member of the client's family: This action violates confidentiality unless the client has given explicit consent for the release of such information.
C. Discussing a client's surgical procedure with the nurse manager: This is usually acceptable within the healthcare team, provided it is done for care coordination or quality improvement purposes and the information is kept confidential.
D. Notifying the provider of physical examination findings: This action is part of standard care procedures and is necessary for the provider to make informed decisions about the client's treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.