A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.

Breath sounds at 1600

Temperature

Urticaria

Blood pressure at 1630

Report of dysphagia

Answer and Explanation

Correct Answer : C,D,E

A.   Bilateral breath sounds clear and present throughout at 1600 are normal findings and do not require immediate follow-up.
B.   The temperature at both 1600 (37.6°C) and 1630 (37.5°C) is slightly elevated but not critically high. It does not require immediate follow-up unless it worsens significantly or is accompanied by other concerning symptoms.
C.   Urticaria (hives) over the chest and trunk, along with itching and difficulty swallowing (dysphagia), are signs of an allergic reaction, which requires immediate follow-up and assessment.
D.   The blood pressure decreased to 78/52 mm Hg at 1630 from 110/58 mm Hg at 1600. This significant drop indicates hypotension and requires immediate follow-up.
E.   Difficulty swallowing (dysphagia) reported by the client suggests a potential airway compromise and requires immediate follow-up to assess the severity and intervene accordingly.

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Correct Answer is B

Explanation

A. This statement describes the current situation, which is part of the "S" (Situation) in SBAR, not the background. Accurate reporting requires separating current findings from background information.
B. Providing the client's history of hypertension is appropriate for the "B" (Background) component. It gives context to the current situation, helping the provider understand potential underlying conditions.
C. This information describes the patient's current assessment and is appropriate for the "A" (Assessment) part of SBAR. Including this in the background can cause confusion and disrupt the communication flow.
D. This statement provides a recommendation and fits into the "R. (Recommendation) part of SBAR. Mixing recommendation with background information can make the communication less clear.

A. "A comprehensive list of medications is provided for the client at the time of discharge." B. "The list obtained from the client does not need to list medications that are not prescribed by the client's provider." C. "A nurse should write a verbal order in the medical record for medications the client was taking at home." D. "Complete the reconciliation process one time when the client is first admitted to the hospital."

Correct Answer is A

Explanation

A. Medication reconciliation involves compiling a comprehensive and accurate list of the patient's current medications, which should be provided to the client at discharge to ensure continuity of care.
B. The list obtained from the client should include all medications the client is taking, including over-the-counter medications and supplements, not just those prescribed by the provider.
C. Verbal orders should be transcribed immediately into the medical record and should not be part of the medication reconciliation process.
D. Medication reconciliation should be an ongoing process throughout the patient's hospital stay to ensure that the most accurate list of medications is maintained.

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A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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A nurse is assisting with the care of a client

Exhibits

Select the 3 findings that require immediate follow-up.