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 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.

A. Hemolysis B. Urticaria C. Fever D. Fluid overload

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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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

Correct Answer is A

Explanation

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Correct Answer is B

Explanation

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