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. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.

A. A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective. B. A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired. C. A nurse documents that a client was shouting and directly quotes the client's words. D. A client overhears an assistive personnel make a false statement about the assigned nurse and requests a different nurse.

Correct Answer is D

Explanation

A. A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective: This does not meet the criteria for slander, as it involves a potential clinical plan of care rather than false statements.
B. A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired: Communication during a private meeting does not constitute slander.
C. A nurse documents that a client was shouting and directly quotes the client's words: Documenting client behavior accurately in the medical record does not qualify as slander.
D. A client overhears an assistive personnel make a false statement about the assigned nurse and requests a different nurse: Slander involves making false verbal statements that harm someone's reputation. If overheard, this constitutes slander.

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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

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