A nurse is preparing to provide 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 rates her pain at a 3 on a 0 to 10 pain rating scale

The client has type 2 diabetes mellitus."

The client is 2 hours postoperative following a cholecystectomy.

The client should wear compression stockings."

Answer and Explanation

The Correct Answer is A

A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:

In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.

B) The client has type 2 diabetes mellitus:

While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.

C) The client is 2 hours postoperative following a cholecystectomy:

The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.

D) The client should wear compression stockings:

Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.

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Correct Answer is B

Explanation

A) Administer PRN haloperidol IM to the client:

Administering haloperidol is not the first-line intervention for managing behavioral disturbances in clients with dementia, especially in response to acute agitation. While antipsychotic medications like haloperidol may be prescribed in some cases, they should be used judiciously due to the risk of adverse effects, particularly in elderly clients. Additionally, administering medication should not be the first action taken without attempting non-pharmacological interventions.

B) Engage the client in a repetitive activity as a distraction:

This is the most appropriate initial intervention when dealing with an agitated client with dementia. Engaging the client in a repetitive, calming activity can help redirect their focus and reduce agitation. Simple, familiar tasks or activities tailored to the client's preferences can be effective in providing comfort and reducing distress.

C) Apply wrist restraints to the client:

Using physical restraints should be avoided unless absolutely necessary for the safety of the client or others. Restraints can cause physical and psychological harm, increase agitation, and compromise the client's dignity and autonomy. Therefore, restraint use should be a last resort and implemented only after other interventions have been attempted and deemed ineffective or when there is an imminent risk of harm.

D) Place the client in a seclusion room:

Seclusion should not be used as an initial intervention for managing agitation in clients with dementia. Seclusion can exacerbate distress and increase feelings of isolation and fear, which may escalate agitation further. It should only be considered as a last resort for managing severe agitation or aggression when all other interventions have failed and there is a risk of harm to the client or others.

A. Assist in checking a unit of packed RBCS to administer to a client. B. Regulate the client's infusion pump after initiating a heparin drip infusion. C. Teach a client about hemodialysis. D. Create a plan of care for a client's discharge.

Correct Answer is ["A","B","C","D"]

Explanation

A) Assist in checking a unit of packed RBCS to administer to a client:

Assisting in checking a unit of packed red blood cells (RBCs) for transfusion is within the nurse's scope of practice. Nurses are responsible for verifying blood products before administration, ensuring compatibility, proper labeling, and appropriate handling to prevent transfusion reactions.

B) Regulate the client's infusion pump after initiating a heparin drip infusion:

Regulating the client's infusion pump after initiating a heparin drip infusion falls within the nurse's scope of practice. Nurses commonly administer and monitor intravenous medications, including heparin drips, and are responsible for regulating the infusion pump to deliver the medication at the prescribed rate.

C) Teach a client about hemodialysis:

Teaching a client about hemodialysis is within the nurse's scope of practice. Patient education is a fundamental aspect of nursing care, and nurses often provide information to clients and their families about various healthcare procedures, treatments, and self-care management, including hemodialysis.

D) Create a plan of care for a client's discharge:

Creating a plan of care for a client's discharge is within the nurse's scope of practice. Nurses are involved in discharge planning, which includes coordinating with the healthcare team, assessing the client's needs, providing education about post-discharge care, arranging follow-up appointments, and ensuring a smooth transition to the next level of care or home.

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A nurse is preparing to provide 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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Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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