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 D

Explanation

A. Makes reference in the nurses' notes of completing an incident report. Incident reports are internal documents and should not be referenced in the client's medical record.
B. Documents that the provider wrote an inaccurate prescription. Documentation should focus on facts, not subjective judgments. Notify the provider instead.
C. Remains logged in to the charting system throughout the shift. Leaving the system open poses a risk for a breach of confidentiality.
D. Includes quotes from the client. Documenting direct quotes ensures accurate representation of the client's statements.

A. "I respect your right to choose to discontinue treatment." B. "I will have a hospice nurse come discuss this kind of care with you." C. "I'll work with hospice services to help you transition to their care." D. "I will answer any questions you have about hospice care honestly."

Correct Answer is D

Explanation

A. "I respect your right to choose to discontinue treatment." This demonstrates respect for autonomy but does not specifically convey veracity (truthfulness).
B. "I will have a hospice nurse come discuss this kind of care with you." This is an appropriate action but does not directly reflect truthfulness.
C. "I'll work with hospice services to help you transition to their care." This statement demonstrates support but does not explicitly involve truth-telling.
D. "I will answer any questions you have about hospice care honestly." This directly addresses the ethical principle of veracity by ensuring truthful communication with the client.

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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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Correct Answer is D

Explanation

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