A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for them? (Select All that Apply.)

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.

Explanation:

A. "We use an automated dispensing device to track the use of controlled substances."

This is a valid statement. Automated dispensing devices (ADDs) help track the use of controlled substances by requiring users to log in, record transactions, and provide an audit trail of medication access.

B. "You are required to have a second nurse witness disposal of a controlled substance."

Having a second nurse witness disposal of controlled substances is a common practice to ensure accountability and prevent diversion. This statement aligns with safety protocols.

C. “If a client refuses a medication, you can place it in your pocket to administer later."

This statement is incorrect and potentially dangerous. Controlled substances should never be pocketed or carried around for later administration, as this increases the risk of diversion and compromises medication safety.

D. "Activities of the automated dispensing machine will be reviewed periodically."

Reviewing the activities of the automated dispensing machine is an essential part of medication safety and helps detect any discrepancies or irregularities in medication access and administration.

E. "We count the amount of a controlled substance available before removal from a medication drawer."

Counting the amount of controlled substances before removal from a medication drawer is a standard procedure to ensure accurate inventory management and detect any discrepancies or losses promptly.