A nurse is receiving change-of-shift report using SBAR to the oncoming nurse or a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?

A. Hold the prescribed dose and notify the provider of the serum potassium level: Holding the dose would be inappropriate because the client’s potassium level is low. Potassium supplementation is indicated to correct the hypokalemia and prevent complications.

B. Give the ordered KCL as prescribed: A potassium level of 3.2 mEq/L indicates mild hypokalemia. Administering the prescribed potassium chloride helps restore normal serum levels and supports cardiac and neuromuscular function, making this the appropriate action.

C. Omit the KCL dose and document that it was not given: Omitting the dose would leave the hypokalemia untreated and put the client at risk for worsening muscle weakness, cardiac arrhythmias, and potential respiratory compromise. Documentation alone does not address the clinical need.

D. Call the lab to verify the client’s results: Verification is not necessary when the value is consistent with the client’s condition and treatment plan. The result of 3.2 mEq/L clearly indicates hypokalemia, and prompt supplementation is the correct intervention.

Rationale for correct choices:

• Orthostatic hypotension: The client’s dizziness when standing, which improves with rest, is characteristic of orthostatic hypotension. This condition can occur due to vasodilation from antihypertensive therapy, such as amlodipine, or age-related cardiovascular changes. Monitoring symptoms and educating the client are essential to prevent falls and injury.
• Instruct the client to avoid sudden position changes: Gradually changing positions allows the cardiovascular system to compensate for shifts in blood pressure. Slow transitions from lying to sitting to standing help reduce dizziness, lightheadedness, and the risk of falls.
• Monitor for orthostatic hypotension: Assessing blood pressure and heart rate in different positions identifies significant drops in systolic or diastolic pressure. Early detection allows timely interventions, such as adjusting medications or providing fluid support, to prevent complications.
• Blood pressure: Continuous monitoring tracks trends and reveals whether the antihypertensive regimen is contributing to symptomatic hypotension. It guides clinical decision-making regarding medication adjustments or additional interventions to maintain hemodynamic stability.
• Heart rate: Monitoring heart rate provides insight into the body’s compensatory response to hypotension. An appropriate increase in heart rate can offset drops in blood pressure, while inadequate compensation may indicate a higher risk for dizziness, syncope, or falls.

Rationale for incorrect choices:

• Pulmonary edema: The client has no shortness of breath, crackles, or edema, which are hallmark signs of pulmonary congestion. This makes pulmonary edema an unlikely cause of the current symptoms, so interventions targeting fluid overload are not indicated.
• Bradycardia: The client’s heart rate is within normal limits (72–78/min) and does not reflect clinically significant bradycardia. Therefore, interventions specific to low heart rate are not needed in this scenario.
• Hyperglycemia: There is no evidence of elevated blood glucose levels or symptoms such as polyuria, polydipsia, or fatigue. Monitoring for hyperglycemia is not relevant to the client’s dizziness associated with orthostatic changes.
• Apply compresses to forehead: While comforting, this does not address the underlying cause of orthostatic hypotension. Symptom relief without addressing postural blood pressure changes does not prevent falls or injury.
• Administer intravenous fluids: IV fluids are only indicated if hypovolemia is present. The client shows stable hydration, so administering fluids would be unnecessary and could potentially cause fluid overload.
• Increased potassium intake: There is no evidence of hypokalemia contributing to the dizziness or hypotension. Potassium supplementation is not indicated in this situation.
• Electrolyte levels: Monitoring electrolytes is not essential here because the client’s symptoms are primarily postural and related to antihypertensive therapy rather than an electrolyte imbalance.
• Respiratory rate: The client’s respiratory rate is normal and not related to orthostatic hypotension. Therefore, focusing on this parameter does not provide actionable information for the current condition.
• Blood glucose levels: There are no indications of diabetes or hyperglycemia contributing to the client’s symptoms, so monitoring blood glucose is unnecessary in this scenario.