A nurse working in a long-term care facility is assigned to care for four clients following the 0700 morning change-of-shift report. Which of the following clients should the nurse attend to first?
A client who has bronchitis, began receiving antibiotics yesterday and has a temperature of 38.3°C (101°F).
A client who has COPD and has an oxygen saturation of 90%.
A client who has Alzheimer's and was restless during the night.
A client who has diabetes and had a 0600 blood glucose level of 60 mg/dL.
The Correct Answer is D
Of the four clients described, the nurse should attend to the client who has diabetes and had a 0600 blood glucose level of 60 mg/dL first. This client's blood glucose level is low and requires immediate intervention to prevent further complications.
Option A may require attention, but the client's condition is stable and they are receiving treatment.
Option B may also require attention, but an oxygen saturation of 90% is within an acceptable range for a client with COPD.
Option C may also require attention, but the client's restlessness during the night does not indicate an immediate need for intervention.
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Correct Answer is B
Explanation
If a float nurse is given a client assignment that requires the use of unfamiliar skills and techniques, the appropriate action for the nurse to take is to request that the charge nurse modify the assignment. This will allow the nurse to provide safe and competent care to their clients.
Option A is incorrect because providing client care as assigned without the necessary skills and knowledge could compromise client safety.
Option C is incorrect because making a formal complaint to the nursing manager is not an immediate solution to the issue at hand.
Option D is incorrect because asking another nurse to trade assignments may not be feasible or appropriate.
Correct Answer is ["A","B","C","E"]
Explanation
SBAR stands for Situation, Background, Assessment, and Recommendation. It is a systematic method of communication that provides a structured framework for conveying important information about a patient. To ensure that the report is thorough, the nurse needs to include information about the situation of the patient, the background leading up to the situation, an assessment of the patient, and recommendations for moving forward.
Option d is incorrect because barriers to providing treatment are not part of the SBAR framework.
Option f is incorrect because the reason why the report is needed is not part of the SBAR framework.
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