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 ["B","C","D"]

Explanation

A. Client 1: Worsening of the pressure injury with purulent drainage indicates infection and failure of pressure injury prevention strategies.
B. Client 5: The stage 3 pressure injury reduced in size and severity to stage 2, with the absence of purulent drainage, indicating wound healing and effective intervention.
C. Client 2: WBC count decreased from 11,500/mm³ to within the normal range at 9,500/mm³, indicating improvement in pneumonia.
D. Client 3: Temperature reduced from 38.9°C to 38°C, with stabilization of vital signs, suggesting improvement in the wound infection.
E. Client 4: An increase in WBCs in the urine from 2 to 6 per low-power field suggests worsening of the urinary tract infection, indicating program ineffectiveness.

A. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day." B. Verify the medication name along with its intended purpose. C. Remind the provider to countersign the prescription in 72 hr. D. Transcribe the medication name using the trade name.

Correct Answer is B

Explanation

A. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day.": This is unnecessary and may cause confusion. "Twice per day" is clear and less prone to misinterpretation during verbal communication.
B. Verify the medication name along with its intended purpose: This is a critical safety measure to ensure that the prescribed medication is appropriate for the client and to prevent errors related to look-alike or sound-alike drug names.
C. Remind the provider to countersign the prescription in 72 hr: This is essential to meet legal and institutional requirements, but it is not the most immediate priority when confirming the prescription.
D. Transcribe the medication name using the trade name: Using generic names is preferable in healthcare documentation to avoid confusion caused by multiple trade names for the same medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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