A patient is admitted to the intensive care unit for congestive heart failure
Using the situation–background–assessment–recommendation (SBAR) format, put the following statements in the order in which the nurse should report changes to the health care team.
a. Our patient was admitted 2 days ago with heart failure and has been receiving furosemide (Lasix) for diuresis, but his urine output has been low.
b. I think that our patient needs to be evaluated immediately and may need intubation and mechanical ventilation.
c. This is the nurse on the surgical unit. I am calling about our patient in room 3. After assessing him, I am very concerned about his shortness of breath.
d. Today, our patient has crackles audible throughout the posterior chest and his O2 saturation is 89%. His condition is very unstable.
ANS:
C, A, D, B
The order of the nurse's statements follows the SBAR format. The nurse explains the situation by identifying herself, then gives the immediate background of the patient. She then assesses the patient and gives her recommendation.
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