A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?
Provider notified of client’s back pain
Request prescription for opioid medication for pain relief
Client is grimacing due to pain
Client admitted with ruptured disc at L5
The Correct Answer is C
Choice A reason: This statement belongs to the recommendation component, as it describes an action that the nurse has taken or suggests to take regarding the client's care.
Choice B reason: This statement also belongs to the recommendation component, as it expresses a need or a request for the client's treatment.
Choice C reason: This statement belongs to the situation component, as it summarizes the current problem or issue that the client is facing.
Choice D reason: This statement belongs to the background component, as it provides relevant information about the client's medical history or diagnosis.
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Related Questions
Correct Answer is C
Explanation
The correct answer is: c. Less time for direct client care
Choice A: Decreased amount of paperwork
Reason: One of the advantages of electronic charting is that it significantly reduces the amount of paperwork. Traditional paper records require extensive manual documentation, which can be time-consuming and prone to errors. Electronic systems streamline this process, making it easier to input and retrieve patient information. Therefore, decreased paperwork is a benefit, not a challenge.
Choice B: Increased number of medication errors
Reason: Electronic charting systems are designed to reduce medication errors by providing features such as electronic prescribing, automated alerts for potential drug interactions, and barcode scanning for medication administration. These systems help ensure that the right medication is given to the right patient at the right time, thereby decreasing the likelihood of errors. Hence, increased medication errors are not typically associated with electronic charting.
Choice C: Less time for direct client care
Reason: One of the significant challenges of electronic charting is that it can be time-consuming, requiring nurses to spend a considerable amount of time on documentation. This can reduce the time available for direct patient care. Nurses often report that the demands of electronic documentation can detract from their ability to engage with patients, perform assessments, and provide hands-on care.
Choice D: Provides evidence of care provided
Reason: Providing evidence of care is a benefit of electronic charting, not a challenge. Electronic health records (EHRs) create a detailed and accurate record of the care provided, which can be easily accessed and reviewed. This documentation is crucial for legal, regulatory, and quality improvement purposes. Therefore, this option does not represent a challenge.
Correct Answer is A
Explanation
Choice A reason: Home care is the most appropriate resource referral for this client, as they will need skilled nursing care to perform wound care and monitor the healing process. Home care can also provide education and support for the client and their family.
Choice B reason: Assisted living is not a suitable resource referral for this client, as they do not provide skilled nursing care or wound care. Assisted living facilities are designed for clients who need assistance with activities of daily living, but not medical care.
Choice C reason: Long-term care is not a necessary resource referral for this client, as they do not have a chronic or terminal condition that requires 24hour nursing care. Long-term care facilities are intended for clients who are unable to live independently due to physical or cognitive impairments.
Choice D reason: Hospice care is not an appropriate resource referral for this client, as they do not have a terminal illness or a life expectancy of less than six months. Hospice care provides palliative care and comfort measures for clients who are dying and their families.
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