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
Explanation
A. Reinforcing teaching with a patient who is learning to walk with a quad cane: Reinforcing teaching can be done by an LVN, as it involves stable, predictable outcomes.
B. A new admission to the unit complaining of chest pain: A new admission with chest pain requires a comprehensive assessment and potential critical thinking and intervention, which are within the scope of an RN.
C. Inserting an NGT for a client who is unable to eat: Inserting an NGT can be done by an RN or LVN, but it does not require the comprehensive assessment and critical thinking that managing a new admission with chest pain does.
D. Calculating intake and output for the unit: Calculating intake and output is a task that can be delegated to a UAP.
Correct Answer is C
Explanation
A. Secondary: Secondary prevention involves early detection and prompt intervention to prevent progression of disease.
B. Disease process: This term does not describe a level of prevention.
C. Tertiary: Tertiary prevention aims to reduce the impact of an ongoing illness or injury that has lasting effects. Rehabilitation after a stroke is an example of tertiary prevention.
D. Primary: Primary prevention aims to prevent disease or injury before it ever occurs.
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