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 A

Explanation

A. "I will begin upon the client's admission to the facility.": Discharge planning should start at admission to ensure that all aspects of the client's care and needs are addressed well before the discharge date.

B. "I will begin once the client's discharge order is written.": Waiting for the discharge order delays the discharge planning process and may result in insufficient preparation for the client’s needs.

C. "I will begin once the client's insurance company approves discharge coverage.": Insurance approval is important but should not delay the initiation of discharge planning, which focuses on the client's needs and readiness for discharge.

D. "I will begin 48 hr before the client's discharge.": Starting discharge planning just 48 hours before discharge may not provide enough time to address all aspects of the client’s care and ensure a smooth transition.

A. Tell the client the physician wants him to take the medications. B. Document that the client refuses the medications. C. Ask the client why he is refusing to take the medications. D. Explain the purpose for the medications.

Correct Answer is D

Explanation

A. Tell the client the physician wants him to take the medications: This does not address the client’s concerns and may not resolve the issue.

B. Document that the client refuses the medications: While documentation is important, the nurse should first address the client’s concerns before documenting.

C. Ask the client why he is refusing to take the medications: Understanding the client’s reasons for refusal is important, but the initial step should be to explain the purpose of the medications.

D. Explain the purpose for the medications: Providing information about the purpose and benefits of the medications helps the client make an informed decision and may address concerns leading to refusal.

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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

Naxlex Comprehensive Predictor Exams

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Correct Answer is A

Explanation

A nurse is preparing to administer medications to a client who states, "I don't want to take those drugs." Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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