A nurse is planning to use the SBAR communication tool when giving on coming shift report. Which of the following statements should the nurse include in the R step?
"There are no provider's prescriptions available."
"The client should be seen by a neurologist."
"The client is disoriented. Pupils are slow to respond to light."
"The client was found unconscious on the floor in her home."
The Correct Answer is B
A. "There are no provider's prescriptions available." This statement is about the current situation or background, not a recommendation.
B. "The client should be seen by a neurologist." The Recommendation (R) step involves suggesting actions or solutions, such as recommending that the client be seen by a neurologist.
C. "The client is disoriented. Pupils are slow to respond to light." This statement belongs in the Assessment (A) step as it describes the nurse’s clinical findings.
D. "The client was found unconscious on the floor in her home." This statement provides background information (B) about the client’s situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. change a sterile dressing: Changing a sterile dressing is a complex task that requires the skills and knowledge of an RN or LPN, not a CNA.
B. Ambulate a stable client to the bathroom: Ambulating a stable client is within the scope of practice for a CNA and can be delegated.
C. take vital signs for the unit: Taking vital signs is a common task for CNAs and can be delegated.
D. Provide morning care to a client: Providing morning care (such as bathing, grooming) is within the scope of practice for a CNA and can be delegated.
E. Give the discharge instructions to a client going home: Giving discharge instructions requires the assessment and judgment of an RN and cannot be delegated to a CNA.
Correct Answer is D
Explanation
A. Proper foot care will be demonstrated to clients during the program: This is specific and measurable but lacks a timeframe and does not clearly define a goal for the clients.
B. A facility will be reserved for the program: This is a task rather than a goal related to client outcomes.
C. Handouts and teaching materials will be distributed: This is another task rather than an outcome goal for clients.
D. Clients will have a decreased incidence of foot ulcers within a month: This is a SMART goal as it is specific, measurable, achievable, relevant, and time-bound. It focuses on a specific health outcome for clients.
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