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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

A. Administering a rectal suppository for a client who has postoperative constipation. B. Instructing a postoperative client to use an incentive spirometer. C. Measuring blood glucose using a monitor for a client who has diabetic ketoacidosis. D. Using a pulse oximeter to measure oxygen saturation for a client who is ready for discharge.

Correct Answer is D

Explanation

Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.

Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.

Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.

Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is D

Explanation

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