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 B

Explanation

A. Close the door to the client's room: This helps contain the fire and prevents smoke from spreading, but it should not be the immediate action after client removal.
B. Activate the alarm outside the client's room: Activating the alarm is critical after ensuring the client's safety, as it alerts the facility to the emergency and mobilizes response teams.
C. Use a Class A fire extinguisher to contain the fire: The type of extinguisher used depends on the fire classification. Attempting to extinguish a fire should occur only after the alarm is activated.
D. Turn off electrical equipment in the client's room: While turning off electrical equipment can reduce fire hazards, it is not the next priority after removing the client.

A. Perform a specific nursing task for a group of clients. B. Provide complete care for a caseload of clients. C. Receive cross-training in multiple departments. D. Delegate low-skilled tasks to assistive personnel.

Correct Answer is B

Explanation

A. Perform a specific nursing task for a group of clients: This approach aligns more with functional nursing, not total patient care.
B. Provide complete care for a caseload of clients: In total patient care, the nurse is responsible for all aspects of care for a specific group of clients during their shift.
C. Receive cross-training in multiple departments: Cross-training is related to float pool or department-specific training, not the care delivery method.
D. Delegate low-skilled tasks to assistive personnel: While delegation may occasionally occur, the focus in total patient care is on the nurse providing direct care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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