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.
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Related Questions
Correct Answer is D
Explanation
A. Provide a schedule of visiting hours to the client's family: While this is important, it is not a priority in the context of initial assessment and history.
B. Develop a plan of care for the client: Developing a plan of care is important but should come after completing the initial assessment and gathering all necessary information.
C. Teach the client about his diagnosis: Teaching about the diagnosis is important but is not a priority over ensuring that crucial health information, such as allergies, is documented.
D. Document the client's allergies in the electronic medical record: Documenting allergies is the priority as it is crucial for preventing potential allergic reactions and ensuring the safety of the client during their care.
Correct Answer is B
Explanation
A. Hemolysis: This is a severe reaction to blood transfusion involving the destruction of red blood cells and requires different management strategies.
B. Urticaria: Diphenhydramine is used to prevent or treat urticaria (hives), which is a mild allergic reaction and can be managed with antihistamines.
C. Fever: This is typically managed with antipyretics or by addressing the underlying cause rather than antihistamines.
D. Fluid overload: This condition requires management with diuretics and careful monitoring of fluid intake rather than antihistamines.
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