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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Correct Answer is D
Explanation
Choice A reason: Outside client's room is not an appropriate area to provide report to the oncoming nurse. This area may not be private or quiet enough to ensure confidentiality and accuracy of the information. The nurse may also miss important cues or changes in the client's condition or environment.
Choice B reason: Conference area is not an appropriate area to provide report to the oncoming nurse. This area may be too far from the client's room or the nursing station, which can delay the response time or the continuity of care. The nurse may also lose the opportunity to interact with the client and the family, and to verify the data with the physical assessment.
Choice C reason: Nurse's lounge is not an appropriate area to provide report to the oncoming nurse. This area may be too informal or distracting to maintain the professionalism and focus of the report. The nurse may also violate the privacy and dignity of the client and the family by discussing their personal or medical information in a public place.
Choice D reason: Client's bedside is an appropriate area to provide report to the oncoming nurse. This area allows the nurse to involve the client and the family in the report, which can enhance their satisfaction, safety, and education. The nurse can also observe the client's condition and behavior, and perform the physical assessment and the medication reconciliation with the oncoming nurse.
Correct Answer is D
Explanation
Choice A reason: SOAP documentation is not the correct method for documenting only unexpected findings. SOAP documentation requires the nurse to document both normal and abnormal findings, as well as the plan of care for the client.
Choice B reason: Problem oriented medical record (POMR) is not the correct method for documenting only unexpected findings. POMR is a method that organizes the documentation around the client's problems, rather than the source of data. It consists of four components: database, problem list, plan, and progress notes.
Choice C reason: Focus charting (DAR) is not the correct method for documenting only unexpected findings. Focus charting is a method that uses the nursing process and the client's perspective to document the client's care. It consists of three components: data, action, and response.
Choice D reason: Charting by exception (CBE) is the correct method for documenting only unexpected findings. CBE is a method that assumes that all standards of care are met unless otherwise documented. It allows the nurse to document only significant or abnormal findings, such as changes in the client's condition, interventions, or outcomes.
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