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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "HIPAA is a federal law, not a state law": This statement is correct. HIPAA is indeed a federal law that sets standards for the protection of health information.

B. "A client's address would be an example of personally identifiable information": This statement is correct. A client's address is considered personally identifiable information under HIPAA.

C. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form": This statement is correct. HIPAA regulates the privacy and security of health information in all forms.

D. "Information about a client can be disclosed to family members at any time": This statement indicates a need for further teaching. HIPAA restricts the disclosure of client information and requires consent or authorization before disclosing information to family members, unless there is a specific exception such as in emergency situations or where the client has consented.

A. Administer pain medication to the first client. B. Weigh the second client. C. Change the dressings of both clients. D. Obtain vital signs for both clients.

Correct Answer is A

Explanation

A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.

B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.

C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.

D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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