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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. The nurse determines the client’s readiness to learn: Assessing the client's readiness to learn is part of the assessment phase of the teaching plan. It involves evaluating the client’s emotional and cognitive state to ensure they are prepared to absorb new information.
B. The nurse discusses types of food that the client needs to avoid: This is part of the teaching or implementation phase, not the assessment phase.
C. The nurse describes which supplies would be needed: Describing necessary supplies is also part of the teaching or implementation phase.
D. Ask the client to demonstrate emptying of the colostomy bag: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the task taught.

A. Reapplying a condom catheter for a client with urinary incontinence B. Feeding a stoke client who has difficulty in swallowing C. Completing a sterile dressing change to a pressure ulcer D. Reinforcing teaching with a client who is learning how to admin

Correct Answer is A

Explanation

A. Reapplying a condom catheter for a client with urinary incontinence: This is a routine task that is appropriate for a nursing assistant to perform under supervision.
B. Feeding a stroke client who has difficulty in swallowing: This task requires careful monitoring for aspiration risks and should be performed by a licensed nurse or speech therapist.
C. Completing a sterile dressing change to a pressure ulcer: This task requires sterile technique and should be performed by a licensed nurse.
D. Reinforcing teaching with a client who is learning how to administer insulin: Teaching and reinforcing education should be performed by a licensed nurse.

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