Hesi Med Surg
Hesi Med Surg ( 34 Questions)
A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?
Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.
Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.
Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.
Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.