Author Question: The nurse is giving report to the next shift and is using the situation, background, assessment, ... (Read 93 times)

bobbie · **on:** Jun 25, 2018

The nurse is giving report to the next shift and is using the situation, background, assessment, recommendation (SBAR) framework for communication. Which of these statements reflects the Background portion of the report?

a. I'm worried that his gastrointestinal bleeding is getting worse.
b. We need an order for oxygen.
c. My name is Ms. Smith, and I'm giving the report on Mrs. X in room 1104.
d. He is 4 days postoperative, and his incision is open to air.

Question 2

The nurse is assessing the IV infusion at the beginning of the shift. Which factors should be included in the assessment of the infusion? Select all that apply.

a. Proper IV solution is infusing, according to the physician's orders.
b. The IV solution is infusing at the proper rate, according to physician's orders.
c. The infusion is proper, according to the nurse's assessment of the patient's needs.
d. Capillary refill in the fingers is checked and noted.
e. The IV site date is noted.
f.
Whether the patient is sufficiently voiding is noted.

nekcihc358 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
During the Background portion, the nurse should state data pertinent to the moment's problem such as the condition of the patient's incision. During the Situation portion, the nurse provides his or her name and the patient's name. During the Assessment portion, the nurse states what he or she thinks is happening (e.g., gastrointestinal bleeding). During the Recommendation portion, the nurse should offer probable solutions or orders that may be implemented.

Answer to Question 2

ANS: A, B, C, E
The nurse should verify that the proper IV solution is hanging and is flowing at the proper rate according to the physician's orders and the nurse's own assessment of the patient's needs. In addition, the nurse should note the date of the IV site and surrounding skin condition. Checking capillary refill is part of the cardiovascular assessment; checking the patient's voiding is part of the genitourinary assessment.