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?

Intracranial pressure readings

Plan of care changes for upcoming shift

Code status

Glasgow score

Answer and Explanation

The Correct Answer is D

A. Intracranial pressure readings: ICP readings are current assessment data and belong in the Assessment segment of SBAR rather than the background. These values help the oncoming nurse interpret the client’s current status but are not part of historical or contextual information.

B. Plan of care changes for upcoming shift: Changes in the plan of care are included in the Recommendation segment of SBAR. This informs the oncoming nurse of anticipated actions but is not part of the client’s background history.

C. Code status: Code status is typically included in the Situation segment, as it is critical for immediate decision-making during emergencies, not background context.

D. Glasgow score: The Glasgow Coma Scale score provides a summary of the client’s neurological status prior to or at the time of the shift report and reflects baseline information relevant to the client’s condition. Including it in the Background segment gives context for current changes and ongoing care.

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Correct Answer is D

Explanation

A. In the area where the nurse obtained the medication: While initial checks for correct medication, dose, and expiration are important at the supply area, the final check must occur immediately before administration to ensure accuracy for the specific client.

B. At the nurses' station while reviewing the provider's prescription: Reviewing the prescription helps prevent errors, but it is not the final point of verification. The medication must be checked at the bedside to confirm the right client, route, and timing.

C. At the time of documentation: Documentation occurs after administration and cannot prevent an error that might happen if the medication is incorrect. Waiting until this point does not ensure safe delivery to the client.

D. At the client's bedside before administration: Performing the final medication check at the bedside is the safest practice. It confirms the correct client, medication, dose, route, and timing immediately before administration, minimizing the risk of medication errors.

A. Two nurses lifting the client under the shoulders B. Two nurses using a friction-reducing device C. One nurse lifting the client's legs as the client uses a trapeze bar D. One nurse lifting as the client pushes with his feet

Correct Answer is B

Explanation

A. Two nurses lifting the client under the shoulders: Lifting under the shoulders increases the risk of musculoskeletal injury for the nurses and can cause discomfort or harm to the client’s shoulders.

B. Two nurses using a friction-reducing device: This is the safest and most effective method for a client who can only partially assist. A slide sheet or similar device reduces shear and friction, protecting the client’s skin while decreasing strain on the nurses.

C. One nurse lifting the client’s legs as the client uses a trapeze bar: This method is suitable only if the client has full upper body strength to pull with the trapeze bar. Since the client is only partially able to assist, relying solely on this strategy would not provide adequate support.

D. One nurse lifting as the client pushes with his feet: This method puts excess physical strain on a single nurse and is not appropriate for a client who requires partial assistance. It also increases the risk of back injury for the nurse.

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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?

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