A nurse is giving 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?

Glasgow results

Intracranial pressure readings

Code status

Plan of care changes for upcoming shift

Answer and Explanation

The Correct Answer is B

A. Glasgow results: This information would typically be included in the "Assessment" section of SBAR, as it relates to the current status of the client.

B. Intracranial pressure readings: This information is appropriate for the "Background" segment of SBAR as it provides relevant context about the client's condition that could impact the plan of care.

C. Code status: This information should be included in the "Background" section if it is relevant to the client's overall care and treatment plan, but it is not specific to the immediate context of the traumatic brain injury.

D. Plan of care changes for upcoming shift: This information belongs in the "Recommendation" or "Plan" section of SBAR, as it involves the actions or changes planned for the client’s care during the upcoming shift.

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Correct Answer is B

Explanation

A. Hemolysis: This is a severe reaction to blood transfusion involving the destruction of red blood cells and requires different management strategies.

B. Urticaria: Diphenhydramine is used to prevent or treat urticaria (hives), which is a mild allergic reaction and can be managed with antihistamines.

C. Fever: This is typically managed with antipyretics or by addressing the underlying cause rather than antihistamines.

D. Fluid overload: This condition requires management with diuretics and careful monitoring of fluid intake rather than antihistamines.

A. Shake the inhaler for 3 to 5 seconds. B. Wait 2 minutes between inhalations. C. Press down twice on the MDI canister. D. Rinse the mouth with mouthwash after inhaling the medication.

Correct Answer is B

Explanation

A. Shake the inhaler for 3 to 5 seconds: While shaking the inhaler is necessary, the recommendation is typically to shake it for 5 seconds before use, not 3.

B. Wait 2 minutes between inhalations: Waiting 2 minutes between inhalations allows time for the medication to work and reduces the risk of side effects. This is a correct practice for using an MDI.

C. Press down twice on the MDI canister: Generally, pressing down once per dose is the correct action. Pressing down twice might not be necessary unless directed by specific instructions.

D. Rinse the mouth with mouthwash after inhaling the medication: It is recommended to rinse the mouth with water, not mouthwash, to prevent oral thrush, especially after using inhaled corticosteroids.

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A nurse is giving 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

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