A nurse is planning to use the SBAR communication tool when giving an oncoming shift report. Which of the following statements should the nurse include in the R step?
There are no provider’s prescriptions available.
The client is disoriented.
Let’s review the client’s orders.
The client was found unconscious on the floor in her home.
The Correct Answer is C
Choice A rationale
This statement does not provide a recommendation for the next steps in the patient’s care. The R step in SBAR stands for Recommendation, which involves suggesting what should be done to address the situation. Stating that there are no provider’s prescriptions available does not fulfill this requirement.
Choice B rationale
This statement is more appropriate for the Assessment step, where the nurse describes the patient’s current condition. The R step should focus on what actions need to be taken next, not just the patient’s current state.
Choice C rationale
This statement is correct because it provides a clear recommendation for the next steps in the patient’s care. The R step in SBAR is meant to suggest what should be done to address the situation, and reviewing the client’s orders is a specific action that can be taken.
Choice D rationale
This statement is more appropriate for the Situation or Background steps, where the nurse describes what has happened to the patient. The R step should focus on what actions need to be taken next, not just the patient’s history.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Evaluation is the phase of the nursing process where the nurse assesses the effectiveness of the interventions and determines whether the patient’s goals have been met. Checking blood sugar before administering insulin is not part of the evaluation phase.
Choice B rationale
Assessment is the phase of the nursing process where the nurse gathers information about the patient’s condition. Checking the client’s blood sugar before administering insulin is an assessment activity, as it involves collecting data to determine the patient’s current blood glucose level.
Choice C rationale
Planning is the phase of the nursing process where the nurse develops a plan of care based on the assessment data. Checking blood sugar is not part of the planning phase; it is an assessment activity.
Choice D rationale
Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the plan of care. While administering insulin is part of the implementation phase, checking blood sugar is an assessment activity that occurs before the implementation of the intervention.
Correct Answer is D
Explanation
Choice A rationale
Correcting the physician’s orders to match the chart is not within the nurse’s scope of practice. Nurses should not alter physician orders.
Choice B rationale
Ignoring the discrepancy is not appropriate. Nurses have a responsibility to ensure patient safety and accurate documentation.
Choice C rationale
Documenting the discrepancy but taking no further action does not address the potential risk to patient safety. Further action is necessary.
Choice D rationale
Documenting the discrepancy and notifying the physician is the correct course of action. This ensures that the physician is aware of the issue and can make any necessary corrections.
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