Case Study: Hand-Off Reports
A nurse is speaking with the provider about a client who has had a change in mental status since admission. Which of the following statements by the nurse demonstrates the use of assertive communication?
"I am concerned about the client's rapid change in mental status." This statement by the nurse is demonstrating the use of an "I" statement, which is a form of assertive communication. The use of the "I" statement by the nurse encourages discussion about the client with the provider and emphasizes the importance of working together for the benefit of the client.
A nurse is preparing to provide a hand-off report for a group of clients to the oncoming nurse. Which of the following information should the nurse include in the report?
"Mr. Jones had pain medication last at 1800." The nurse should include critical data related to the client's care, such as when the client last received a PRN pain medication, when providing a hand-off report.
A nurse is teaching a newly licensed nurse about telephone reporting using the SBAR acronym. Which of the following responses by the newly licensed nurse indicates an understanding of the teacher?
"S stands for situation." The nurse should identify that "S" stands for the "situation" of the client when providing a telephone report using the SBAR acronym.
A nurse is providing a transfer report to an inpatient rehabilitation facility for a client who has atrial fibrillation. Which of the following pieces of information is the priority for the nurse to include in the report?
"Today's INR is 2.0." The greatest risk to this client is injury from bleeding, due to an increased INR as a result of receiving anticoagulant therapy for atrial fibrillation; therefore, this is the priority piece of information the nurse should include in the transfer report.
A nurse is providing a hand-off report to another nurse for a client who is newly admitted and has Crohn's disease. Which of the following information is the priority for the nurse to include in the report?
Hgb 6.8 g/dL The greatest risk to this client is injury from bleeding; therefore, this is the priority piece of information the nurse should include in the hand-off report.
