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 D

Explanation

A. Delegate low-skilled tasks to assistive personnel.

Delegating low-skilled tasks to assistive personnel is not consistent with the total patient care delivery method. In this model, the nurse assumes responsibility for providing comprehensive care to a smaller number of patients rather than delegating tasks to others. The nurse remains directly involved in all aspects of patient care, including assessment, planning, implementation, and evaluation.

B. Receive cross-training in multiple departments

Receiving cross-training in multiple departments may be beneficial in some healthcare settings but is not a characteristic of the total patient care delivery method. This model focuses on nurses providing individualized care to a specific group of patients within their assigned unit. Cross-training in multiple departments would not align with this model, as it could lead to divided attention and potentially compromise the quality of care provided.

C. Perform a specific nursing task for a group of clients.

Performing a specific nursing task for a group of clients is not consistent with the total patient care delivery method. In this model, the nurse is responsible for providing comprehensive care to a smaller number of patients, rather than focusing on specific tasks for multiple patients. Each patient's care is individualized and encompasses all aspects of nursing care, not just specific tasks.

D. Provide complete care for a caseload of clients.

Providing complete care for a caseload of clients is characteristic of the total patient care delivery method. In this model, the nurse assumes responsibility for the holistic care of a smaller number of patients during each shift. This approach allows for continuity of care, fosters therapeutic nurse-patient relationships, and promotes better patient outcomes.

A. A newborn has an Apgar score of 7 at 5 min after birth. B. A newborn has respiratory distress and requires oxygen. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

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