A nurse in an emergency department is preparing change-of-shift report for an adult client who is transferring to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the report? (Select all that apply.)
The client has a do-not-resuscitate (DNR) prescription.
The client has a continuous IV of lactated Ringer's.
The client was straight catheterized for 350 mL 2 hr ago.
The client has Medicare insurance.
The client lives in a one-story home.
Correct Answer : A,B,C
A. The client has a do-not-resuscitate (DNR) prescription: Including the client’s code status is essential for ensuring that the receiving medical-surgical team follows the appropriate resuscitation plan. This information directly impacts emergency decision-making and aligns with the client's wishes.
B. The client has a continuous IV of lactated Ringer’s: Reporting active IV fluids is necessary for continuity of care, as it affects fluid balance, medication administration, and overall treatment planning. The receiving nurse must be aware of the infusion to monitor for effectiveness and complications.
C. The client was straight catheterized for 350 mL 2 hr ago: Details about recent procedures, such as urinary catheterization, are relevant to ongoing assessment and care. Monitoring urinary output helps evaluate kidney function and fluid status, making it crucial information for the next shift.
D. The client has Medicare insurance: Insurance details are important for administrative and billing purposes but do not directly impact immediate patient care. This information is typically managed by case management or the hospital’s financial services.
E. The client lives in a one-story home: While discharge planning may involve assessing home arrangements, this detail is not immediately necessary for a shift report. Relevant home considerations should be discussed later when planning for discharge and follow-up care.
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Related Questions
Correct Answer is C
Explanation
A. "Do you spend more time thinking about the past, present, or future?": This question focuses on the client's perspective of time rather than their beliefs about environmental control. While it may provide insight into the client's worldview, it does not directly address how they perceive their ability to influence their health or environment.
B. "Who makes most of the decisions in your family group?": This question may provide some understanding of family dynamics and authority but does not directly assess the client's beliefs regarding their control over their health or environment. It may highlight cultural aspects but lacks a direct connection to environmental control beliefs.
C. "What do you think you can do to affect your health status?": This question directly addresses the client's beliefs about their ability to exert control over their health and environment. It encourages the client to reflect on their agency and the actions they believe they can take to influence their well-being, making it the most relevant choice for assessing environmental control.
D. "Can you list any diseases that your parents or siblings have had?": While understanding the family medical history is important, this question focuses on genetics and familial health rather than the client’s beliefs about their ability to control their environment or health. It does not provide insight into how the client views their role in managing their health.
Correct Answer is B
Explanation
A. Suggest that family members discuss the importance of the surgery with the client: While family support can be valuable, the decision ultimately lies with the client. It is essential for the client to feel empowered in their choices without feeling pressured by family members.
B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure: The most appropriate action is to inform the surgeon of the client's decision to withdraw consent. It is the client's right to change their mind about the procedure at any time before it occurs, and the healthcare team must respect and facilitate that decision.
C. Document the risks of refusing the procedure in the client's medical record: While documenting the client's decision is important, focusing solely on the risks of refusal may not be appropriate at this time. The primary concern should be to ensure that the client's wishes are communicated to the healthcare provider.
D. Discuss the benefits of the procedure with the client: Emphasizing the benefits of the procedure may unintentionally pressure the client. It is more important to respect the client's autonomy and decision-making, ensuring they are comfortable with their choice without feeling coerced into changing their mind.
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