A patient is nauseated and vomited. She has a red rash on the face and neck, which she says is itchy. She complains of a headache and feels very irritable. Which piece of data is objective?

A. Begin nursing interventions without needing an initial assessment: This option is not appropriate. A thorough assessment is crucial before any interventions are initiated. The nurse needs to understand the patient's current condition, medical history, and specific needs to provide safe and effective care.

B. Use critical thinking skills to organize care for the patient: Correct. Reviewing the nursing care plan allows the nurse to critically think about the patient's needs, plan interventions accordingly, and organize care effectively. It helps in understanding the patient's unique requirements and tailoring the care plan to meet those needs.

C. Make revisions in the plan as indicated by the shift report: This option implies that the nurse can modify the care plan based on the shift report. While shift reports are essential for continuity of care, the initial review of the care plan is more about understanding the existing plan and adapting it based on the patient's condition, not just the shift report.

D. Skip the shift report and begin with the initial assessment: This option is not appropriate. Both the shift report and the initial assessment are crucial components of patient care. The shift report provides important information from the previous nursing staff, and the initial assessment is the first step in understanding the patient's current state.

A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.

B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.

Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.

C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.

D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.