A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Plan of care changes for the upcoming shift

Intracranial pressure readings

Glasgow results

Code status

Answer and Explanation

The Correct Answer is D

Choice A reason: Plan of care changes for the upcoming shift

Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.

Choice B reason: Intracranial pressure readings

Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.

Choice C reason: Glasgow results

The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.

Choice D reason: Code status

Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.

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Correct Answer is ["2.0"]

Explanation

To calculate the dosage, follow these steps:

Step 1: Identify the prescribed dose.

The prescribed dose is 25 mg.

Result: 25 mg.

Step 2: Identify the concentration of the medication.

The concentration is 12.5 mg/mL.

Result: 12.5 mg/mL.

Step 3: Calculate the volume to administer.

Volume (mL) = (Prescribed dose in mg) ÷ (Concentration in mg/mL).

Volume (mL) = 25 mg ÷ 12.5 mg/mL.

Volume (mL) = 2 mL.

Result: 2 mL.

So, the nurse should administer 2.0 mL of diphenhydramine elixir per dose.

A. Administer 50,000 units of heparin by IV bolus every 12 hours. B. Have vitamin K available on the nursing unit. C. Use tubing specific for heparin sodium when administering the infusion. D. Check the activated partial thromboplastin time (aPTT) every 6 hours.

Correct Answer is D

Explanation

Choice A reason:

Administer 50,000 units of heparin by IV bolus every 12 hours: This dosage is incorrect and potentially dangerous. Heparin dosing must be carefully calculated based on the patient’s weight and coagulation test results. Standard practice involves adjusting the dose according to the aPTT levels to maintain therapeutic anticoagulation.

Choice B reason:

Have vitamin K available on the nursing unit: Vitamin K is the antidote for warfarin, not heparin. The antidote for heparin is protamine sulfate. Having the correct antidote available is crucial for managing potential bleeding complications associated with heparin therapy.

Choice C reason:

Use tubing specific for heparin sodium when administering the infusion: While it is important to use appropriate tubing for any IV medication, there is no specific tubing required exclusively for heparin sodium. Standard IV tubing is typically sufficient.

Choice D reason:

Check the activated partial thromboplastin time (aPTT) every 6 hours: This is correct. Monitoring aPTT levels is essential when administering a continuous heparin infusion. The aPTT test measures the time it takes for blood to clot and helps ensure that the heparin dose is within the therapeutic range. Regular monitoring helps prevent both under- and over-anticoagulation, reducing the risk of clotting or bleeding complications.

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A nurse is giving a change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2.0"]

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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