A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

"The client is 2 hours postoperative following a cholecystectomy."

"The client rates her pain at a 3 on a 0 to 10 pain rating scale."

"The client has type 2 diabetes mellitus."

"The client should wear compression stockings."

Answer and Explanation

The Correct Answer is B

A.   "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B.   "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C.   "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D.   "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.

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Correct Answer is C

Explanation

A. Examine the outcomes: This step comes later in the process when evaluating potential decisions and their consequences.
B. Determine possible alternatives: Identifying possible alternatives occurs after defining the problem to explore appropriate solutions.
C. Identify the problem. The first step in the ethical reasoning process is to clearly identify and define the ethical problem or dilemma. Understanding the issue provides the foundation for gathering relevant information, analyzing the situation, and making an informed decision.
D. Develop a plan of action: Developing an action plan is one of the final steps after considering the ethical principles, possible alternatives, and anticipated outcomes.

A. Select the appropriate dressing. B. Document the dressing change. C. Change the dressing. D. Review available dressing types.

Correct Answer is D

Explanation

A. Select the appropriate dressing: Although selecting the right dressing is essential, it is not the initial step.
B. Document the dressing change: Documentation follows the intervention, not precedes it.
C. Change the dressing: Performing the dressing change without adequate preparation is not the first step.
D. Review available dressing types: Reviewing available dressing options ensures appropriate selection based on the wound's condition and treatment goals.

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A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

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