A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?

Two staff members have called to say they will be absent.

Transport assistance is unavailable to take a client to occupational therapy.

The emergency department nurse is waiting to give report on a new admission

A nurse on the previous shift wrote an incident report about a medication error.

Answer and Explanation

The Correct Answer is C

A.   Staffing issues are important as they can affect the workload and safety of the unit. However, the immediate concern is usually related to direct patient care. This situation should be addressed promptly to ensure coverage and proper delegation of tasks, but it is not the most urgent concern compared to issues directly affecting patient safety or emergency situations.
B.   While this issue affects the logistical aspects of patient care, it is less critical compared to urgent patient care needs or emergencies. Arranging alternative transport solutions or rescheduling the therapy session should be addressed, but it is not as immediate as other concerns.
C.   This situation should be addressed first because timely handoff of patient information is crucial for continuity of care. The new admission could require immediate attention, and a delay in receiving the report could impact patient care.
D.   While an incident report about a medication error is significant and should be reviewed and addressed, it does not require immediate action in the same way that ensuring patient care continuity does. The charge nurse should review the incident report and follow up as necessary, but it is not as urgent as the need to receive a report on a new admission from the emergency department.

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Correct Answer is C

Explanation

A. The client’s code status (e.g., full code, do not resuscitate) is crucial information for any healthcare provider, especially when transferring care. However, this detail is typically included in the Situation or Assessment sections rather than the Background. It is important to communicate the code status clearly, but it is not part of the historical or contextual information provided in the Background section.
B. While the client's name is important for identification, it is usually not detailed in the Background section. Instead, it is generally included at the beginning of the report or in the Situation section where initial identification and immediate concerns are presented.
C. Information about a prescribed consultation (e.g., a referral to a specialist) falls under the Background section of the SBAR. This part of the report should include pertinent historical details and context, such as any previous consultations or significant events that have impacted the client’s current condition.
D. Vital signs are crucial for assessing the current status of the client but are usually included in the Assessment section of the SBAR. This section provides a summary of the client’s current condition, including vital signs, lab results, and other relevant clinical data.

A. Attach the restraints to the fixed portions of the frame of the client's bed. B. Remove the client's restraints every 2 hr C. Secure the client's restraints with a square knot. D. Allow 1 fingerbreadth between the restraint and the client's wrists.

Correct Answer is D

Explanation

A. Restraints should not be attached to the bed frame. Instead, they should be secured to a movable part of the bed (such as side rails) to prevent injury. Attaching restraints to the bed frame can cause harm to the patient and limit their mobility.
B. While it's essential to assess and reposition restraints regularly, removing them entirely every 2 hours is not recommended unless the patient's condition allows for it. Restraints should be removed and repositioned at least every 2 hours to assess skin integrity, circulation, and comfort. However, they should not be removed entirely unless necessary.
C. Square knots are not recommended for restraining patients because they can be difficult to untie quickly in case of an emergency. Quick-release buckles or Velcro fasteners are safer options.
D. Allowing 1 fingerbreadth between the restraint and the client's wrists ensures proper circulation and prevents excessive tightness. Properly fitting restraints prevent injury while maintaining patient safety.

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A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

Correct Answer is C

Explanation

A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

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