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 code status
The client's vital signs
The client's name
A prescribed consultation
The Correct Answer is C
Choice A reason: The client's code status is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. The code status indicates the level of resuscitation the client wishes to receive in case of a cardiac or respiratory arrest.
Choice B reason: The client's vital signs are not part of the background information, but rather the assessment section of the SBAR Communication tool. The vital signs reflect the client's current condition and response to treatment.
Choice C reason: The client's name is part of the background information, along with the client's age, diagnosis, reason for admission, and relevant medical history. The background information provides a brief overview of the client's situation and helps to identify the client.
Choice D reason: A prescribed consultation is not part of the background information, but rather the recommendation or request section of the SBAR Communication tool. A consultation is a referral to another health care professional for further evaluation or management of the client's condition.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Accompanying a client who just had a wound debridement to physical therapy is not a task that the nurse should assign to the LPN, as it requires the nurse to monitor the client's vital signs, wound status, and pain level. The nurse should accompany the client and delegate other tasks to the LPN or the assistive personnel.
Choice B reason: Providing postmortem care for a client who has just died is not a task that the nurse should assign to the LPN, as it requires the nurse to verify the death, notify the provider and the family, and document the care. The nurse should provide postmortem care and delegate other tasks to the LPN or the assistive personnel.
Choice C reason: Obtaining a urine specimen from an older adult client is not a task that the nurse should assign to the LPN, as it is a basic skill that the assistive personnel can perform. The nurse should assign this task to the assistive personnel and supervise their work.
Choice D reason: Reinforcing dietary teaching with a client who has heart disease is a task that the nurse should assign to the LPN, as it is within the LPN's scope of practice to reinforce the teaching that the nurse has initiated. The nurse should provide the initial teaching and evaluate the client's learning.
Correct Answer is C
Explanation
Choice A reason: This is not an appropriate action by the staff nurse. The incident report should not be sent to the ethics committee, as it is not a part of the client's record and does not involve ethical issues. The incident report should be sent to the risk management department, which is responsible for identifying and preventing potential hazards and liabilities in the health care setting.
Choice B reason: This is not an appropriate action by the staff nurse. The names of witnesses to the fall should not be listed in the nurses' notes, as they are not relevant to the client's care and may violate confidentiality. The names of witnesses should be included in the incident report, which is a confidential document that is not part of the client's record.
Choice C reason: This is an appropriate action by the staff nurse. The client's account of the fall should be included in the incident report, as it provides valuable information about the circumstances and causes of the fall. The incident report should also include the date, time, location, and description of the fall, the staff members involved, the interventions taken, and the client's condition and response.
Choice D reason: This is not an appropriate action by the staff nurse. The fact that an incident report was filed should not be documented in the client's record, as it may imply negligence or fault and may be used as evidence in a legal case. The incident report is a separate document that is used for quality improvement and risk management purposes.
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