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. Administer the medication using a Z-track technique: This is correct as ceftriaxone should be administered using the Z-track technique to prevent leakage of the medication into the subcutaneous tissue and minimize irritation.
B. Administer the medication using a 5/8-inch needle: A longer needle is typically needed for IM injections to reach the muscle tissue, so a 5/8-inch needle is not appropriate.
C. Administer the medication in the deltoid muscle: Ceftriaxone is usually administered in the larger muscle groups such as the ventrogluteal or vastus lateralis muscles rather than the deltoid.
D. Administer the medication at a 45° angle: IM injections are generally given at a 90° angle to ensure that the medication is properly deposited into the muscle tissue.
Correct Answer is B
Explanation
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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