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 ["A","B","C","D","E","F"]
Explanation
A. Recommend use of a safety alert device when home alone: Implementing a safety alert device is crucial for the client living alone, as it provides a means to call for help in case of a fall or other emergencies. This enhances the client's safety and ensures timely assistance if needed.
B. Collaborate with physical therapy to assess client needs: Involving physical therapy is essential for evaluating the client's mobility and determining appropriate interventions for safe transition to home. Physical therapists can provide guidance on using a walker and suggest exercises to improve strength and balance.
C. Facilitate obtaining assistive devices for home setting: Ensuring that the client has the necessary assistive devices, such as a walker or grab bars, is important for promoting safety and independence in the home environment. This helps reduce the risk of future falls.
D. Collaborate with client and family to implement fall prevention plan: Working with the client and their adult child to develop a comprehensive fall prevention plan addresses the client's history of falls. This plan can include education on safe movement, environmental modifications, and strategies to prevent future falls.
E. Perform a home hazard assessment: Conducting a home hazard assessment is critical for identifying potential risks that could lead to falls or injuries. This assessment allows for targeted interventions to modify the home environment, enhancing safety for the client.
F. Educate client about the effect their medications have on their balance: Understanding the potential side effects of medications, such as metoprolol, on balance and coordination is important for the client. This knowledge can empower them to take precautions and report any concerning symptoms to their healthcare provider.
G. Place no smoking signs in client's home: While promoting a smoke-free environment is beneficial, it is not directly related to the client’s current health concerns regarding falls and recovery from a hip fracture. Therefore, this intervention is less relevant to the discharge planning process in this context.
Correct Answer is B
Explanation
A. Have adolescents lead peer discussions in schools about safe sexual practices: While this intervention promotes education and awareness, it primarily addresses social and educational factors rather than financial ones. It focuses on behavior change among peers rather than directly impacting financial barriers to healthcare access.
B. Distribute condoms through remote community clinics: This intervention directly addresses financial factors affecting community health by ensuring access to condoms, which may otherwise be a financial burden for some individuals. Providing free condoms helps reduce the economic barriers to safe sex practices and promotes better sexual health in the community.
C. Create commercial advertisements describing the long-term effects of HIV: While advertisements can raise awareness about HIV and its consequences, this intervention focuses on informational and awareness aspects rather than directly addressing financial barriers to health services or prevention resources.
D. Include information about perinatal HIV transmission at prenatal education classes: This intervention enhances education regarding HIV transmission but primarily addresses health education rather than financial factors. While it is crucial for preventing transmission, it does not focus on overcoming financial barriers that may limit access to necessary resources or care.
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