A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

"The client is 2 hours postoperative following a cholecystectomy."

"The client rates her pain at a 3 on a 0 to 10 pain rating scale."

"The client has type 2 diabetes mellitus."

"The client should wear compression stockings."

Answer and Explanation

The Correct Answer is B

A.   "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B.   "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C.   "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D.   "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.

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Correct Answer is D

Explanation

A. Cover the site with a stockinette dressing: This action may help secure the IV site but does not immediately address the safety concern.
B. Administer a sedative: Administering sedatives is not the first-line intervention and requires a provider's order.
C. Apply a soft mitten restraint: Restraints should be the last resort after implementing less restrictive measures. Closer observation and attempts to redirect the client are less restrictive and should be tried first.
D. Place the client close to the nurses' station: Proximity allows for frequent monitoring, preventing further self-harm.

A. Inform the charge nurse. B. Send the client for the test with the unsigned form. C. Obtain consent from a family member. D. Wake the client and ask them to sign the form.

Correct Answer is A

Explanation

A. Inform the charge nurse. The charge nurse should be notified when consent cannot be obtained so appropriate steps can be taken, such as rescheduling or involving the healthcare provider.
B. Send the client for the test with the unsigned form. Consent must be obtained before any invasive procedure. Proceeding without consent can result in legal and ethical consequences.
C. Obtain consent from a family member. A family member cannot give consent unless they hold legal power of attorney for healthcare decisions.
D. Wake the client and ask them to sign the form. Consent obtained under the influence of sedatives is not legally valid as it compromises the client's decision-making capacity.

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A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is disoriented and has removed their IV catheter. After observing the RN reinsert the IV catheter, which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has a prescription for an invasive procedure that requires consent. When the nurse arrives at the bedside to obtain the client's signature they find that the client is asleep after receiving a sedative. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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