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 A
Explanation
A. Pull the auricle down and out: For a child under 3 years old, the ear canal is more horizontal, so the auricle should be pulled down and out to straighten the ear canal for proper instillation of ear drops.
B. Pull the auricle up and back: This technique is used for children older than 3 years old, as their ear canal becomes more vertical.
C. Pull the auricle up and out: This technique is incorrect for a 3-year-old child as it does not account for the horizontal position of the ear canal in younger children.
D. Pull the auricle down and back: This technique is not recommended for ear drops in young children and does not align with the anatomical considerations for their ear canal.
Correct Answer is A
Explanation
A. Documents medication administration prior to administering it: This is incorrect practice. Medication administration should be documented only after it has been given to ensure accuracy and accountability.
B. Checks the provider's orders and confirmed dosage in a medication reference guide: This is a correct practice to ensure that the medication order and dosage are accurate.
C. Scans the bar code on the medication administration record and the client's arm band: This is a correct practice to verify the medication and patient identity, enhancing safety.
D. Verifies the medication against the prescription and medication label: This is a correct practice to confirm that the correct medication and dosage are administered.
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