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 D

Explanation

A. Tell the client they are wrong: Telling the client they are wrong is dismissive and does not foster a therapeutic relationship.
B. Ask the client why they think that way: Asking the client why they think that way may provide insight, but it does not clarify the difference between an allergy and an intolerance.
C. Ignore the comment and proceed with the teaching plan: Ignoring the comment is not appropriate as it fails to address the client’s concern and provide necessary education.
D. Explain to the client the difference between medication intolerance and allergy: This response provides education and clarifies the difference, helping the client understand their reaction to the medication.

A. Proper foot care will be demonstrated to clients during the program. B. A facility will be reserved for the program C. Handouts and teaching materials will be distributed. D. Clients will have a decreased incidence of foot ulcers within a month time.

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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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?

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