A nurse is preparing to provide change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?
The client rates her pain at a 3 on a 0 to 10 pain rating scale
The client has type 2 diabetes mellitus."
The client is 2 hours postoperative following a cholecystectomy.
The client should wear compression stockings."
The Correct Answer is A
A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:
In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.
B) The client has type 2 diabetes mellitus:
While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.
C) The client is 2 hours postoperative following a cholecystectomy:
The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.
D) The client should wear compression stockings:
Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Verify the medication name along with its intended purpose.
Rationale:
Verifying the medication name along with its intended purpose is crucial to ensure accuracy and patient safety. In this scenario, the nurse should confirm that the medication name "propranolol" matches the intended medication prescribed by the provider. Additionally, understanding the purpose of the medication ensures that the nurse can correctly communicate this information to the patient, reinforcing patient education and adherence to the prescribed treatment plan. Verifying the medication name and purpose helps prevent medication errors and promotes safe medication administration practices.
B. Verbalize the letters "B-I-D" for the dosing instead of saying "twice per day."
Verbalizing the letters "B-I-D" for the dosing frequency instead of saying "twice per day" is not the most appropriate action in this situation. While using medical abbreviations like "B-I-D" (which stands for "bis in die" or "twice a day") is common in healthcare settings, it's essential to ensure clear communication with all involved parties, including patients and providers. Using layman's terms like "twice per day" helps avoid confusion and promotes better understanding, reducing the risk of medication errors due to misinterpretation.
C. Transcribe the medication name using the trade name.
Transcribing the medication name using the trade name is not appropriate unless specifically instructed by the provider or if there is a specific reason to do so. In this scenario, the nurse should use the generic name "propranolol" when transcribing the medication to ensure consistency and accuracy in documentation and communication. Using trade names can lead to confusion, especially in environments where multiple brand names may exist for the same generic medication.
D. Remind the provider to countersign the prescription in 72 hr.
Reminding the provider to countersign the prescription in 72 hours is not relevant to the immediate task of verifying and reading back the prescription information. While ensuring proper documentation and authorization of prescriptions is important, it should not be addressed during the initial verification and communication process. This action can be addressed separately, following the completion of the prescription verification process.
Correct Answer is B
Explanation
A) Contact the nurse from the previous shift to report the doubled dose:
While it may be appropriate to communicate with the nurse from the previous shift to gather information about the medication administration, contacting them solely to report the doubled dose may not be the most effective action. The priority is to ensure appropriate documentation of the incident and take necessary steps to address it.
B) Document the doubled dose in the client's medical record:
Documenting the doubled dose in the client's medical record is essential for accurate and transparent documentation of the incident. This documentation should include details such as the medication, dosage, time of administration, and any actions taken in response to the error. It ensures that all members of the healthcare team are aware of what occurred and facilitates appropriate follow-up and monitoring.
C) Place a copy of the incident report in the client's record:
While completing an incident report is necessary to formally document the medication error and initiate an investigation, simply placing a copy of the report in the client's record may not be sufficient. The incident report typically serves as an internal document used for quality improvement purposes and may not be part of the client's official medical record.
D) Report the incident to the manager of the pharmacy:
Reporting the incident to the manager of the pharmacy may be appropriate for addressing potential medication dispensing errors or system issues but may not be the immediate action required when a medication error occurs at the administration stage. The first priority is to ensure accurate documentation of the error in the client's medical record.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
