A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?
Client's present condition.
Suggestions for the provider regarding client care.
Physical findings.
Previous treatments.
The Correct Answer is A
Choice A rationale:
In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.
Choice B rationale:
Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.
Choice C rationale:
Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.
Choice D rationale:
Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Teaching the most crucial content early in the session is an effective strategy to engage learners and ensure that they receive essential information. This approach captures their attention and provides a solid foundation for the rest of the session. It helps establish relevance and interest, keeping the learners engaged throughout the educational program.
Choice B rationale:
Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.
Choice C rationale:
Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.
Choice D rationale:
Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.
Correct Answer is ["A"]
Explanation
The correct answer is Choice A.
Choice A rationale: Administering enoxaparin 40 mg subcutaneously in the deltoid site is incorrect. Enoxaparin is typically administered in the abdomen or thigh to ensure proper absorption and minimize the risk of injury. Administering it in the deltoid requires an incident report for protocol deviation.
Choice B rationale: Advancing the urinary catheter 18 cm (7 in) is standard practice for male clients to ensure the catheter reaches the bladder. There is no indication of error or the need for an incident report as this action follows proper procedure.
Choice C rationale: Cleansing a wound with 0.99% sodium chloride irrigation prior to collecting a specimen for culture is standard practice. This action ensures the wound is free from surface contaminants and does not necessitate an incident report.
Choice D rationale: Flushing the tubing of a continuous enteral feeding with 30 mL of water is standard practice to maintain patency and ensure the effectiveness of the feeding. This procedure follows guidelines and does not require an incident report.
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