A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
The client's vital signs
The client's name
The client's code status
A prescribed consultation
The Correct Answer is B
Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.
Choice B reason: The client's name is part of the background information, as it identifies the client and establishes rapport. The name should be the first thing the nurse says when initiating the SBAR communication.
Choice C reason: The client's code status is not part of the background information, but rather the recommendation information. The code status should be communicated at the end of the SBAR communication, along with any other suggestions or requests for the receiving nurse.
Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering a bronchodilator two times a day for a child who has cystic fibrosis is an appropriate intervention, as it helps to improve the child's respiratory function and prevent mucus accumulation.
Choice B reason: Checking the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago is an appropriate intervention, as it helps to monitor the child's circulation and nerve function and detect any signs of compartment syndrome.
Choice C reason: Maintaining eye shields for a newborn receiving phototherapy for hyperbilirubinemia is an appropriate intervention, as it helps to protect the newborn's eyes from the harmful effects of the light and prevent eye damage.
Choice D reason: Teaching an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet is an incorrect intervention, as it contradicts the dietary recommendations for this condition. A high-protein, low-fiber diet can worsen the inflammation and symptoms of ulcerative colitis. The nurse should teach the adolescent about a low-residue, high-calorie, high-protein diet instead.
Correct Answer is C
Explanation
Choice A reason: Report of photophobia is a common finding in clients who have meningitis, as the inflammation of the meninges causes sensitivity to light. However, this is not an urgent finding that requires immediate reporting to the provider.
Choice B reason: Increased temperature is a common finding in clients who have meningitis, as the infection causes fever and systemic inflammation. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is very high or accompanied by other signs of sepsis.
Choice C reason: Decreased level of consciousness is an urgent finding in clients who have meningitis, as it indicates increased intracranial pressure, cerebral edema, or brain herniation. These are life-threatening complications that require immediate intervention and treatment.
Choice D reason: Generalized rash over trunk is a common finding in clients who have meningococcal meningitis, as the bacteria cause petechiae and purpura on the skin. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is extensive or associated with bleeding or shock.
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