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 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.
Correct Answer is C
Explanation
A. Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side: The direction of the snap is not as critical as ensuring the use of proper technique to avoid injury and contamination.
B. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion: Breaking the ampule downward could risk contamination and injury if not done properly.
C. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body: This method minimizes the risk of glass shards and helps to prevent injury and contamination, ensuring safe handling of the medication.
D. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body: Breaking the ampule toward the body is unsafe and increases the risk of injury from glass shards.
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