A nurse is preparing to provide 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 rates her pain at a 3 on a 0 to 10 pain rating scale

The client has type 2 diabetes mellitus."

The client is 2 hours postoperative following a cholecystectomy.

The client should wear compression stockings."

Answer and Explanation

The Correct Answer is A

A) The client rates her pain at a 3 on a 0 to 10 pain rating scale:

In the SBAR communication technique, "A" stands for "Assessment." This portion of the report should include concise and pertinent information about the client's current condition or status. The client's pain level, rated on a standardized pain scale, is a crucial assessment parameter that provides immediate insight into the client's comfort and potential need for intervention or further assessment.

B) The client has type 2 diabetes mellitus:

While the client's medical history of type 2 diabetes mellitus is important information, it is more relevant to the client's overall health status and background. In the SBAR framework, this information would typically be included in the "B" (Background) portion of the report, which focuses on contextual information such as medical history, current diagnoses, and relevant background information about the client.

C) The client is 2 hours postoperative following a cholecystectomy:

The fact that the client is 2 hours postoperative following a cholecystectomy is significant information regarding the client's recent surgical procedure and immediate postoperative status. However, this information falls under the "B" (Background) portion of the SBAR report, which includes details about the client's recent events, procedures, or treatments.

D) The client should wear compression stockings:

Information about the client's prescribed interventions or treatments, such as wearing compression stockings, is essential for continuity of care and ensuring that appropriate interventions are continued. However, this information is typically included in the "R" (Recommendation) portion of the SBAR report, where the nurse may provide recommendations for ongoing care or interventions based on the client's current condition and needs.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Determine which clients need priority medical treatment: This task requires clinical judgment and assessment skills beyond the scope of practice for assistive personnel. Nurses are responsible for assessing clients' needs during emergencies and determining priority for medical treatment based on the severity of their conditions.

B) Answer questions from area residents who have health concerns: While it's important to provide information and support to those affected by the tornado, answering questions about health concerns requires knowledge and expertise in healthcare that is typically within the nurse's scope of practice. Nurses should address inquiries and provide education to ensure the well-being of the community.

C) Perform CPR for a client who is not breathing: This task can be delegated to assistive personnel if they are trained and competent in CPR. In emergencies such as cardiac arrest, prompt initiation of CPR can be life-saving. However, it's crucial to ensure that the assistive personnel are properly trained and certified in CPR before delegating this task.

D) Complete distal capillary refill checks for a client who has an open leg wound: While assessing capillary refill is an important aspect of wound care, performing this task for a client with an open leg wound requires specialized knowledge and skills in wound assessment and management. It falls within the scope of nursing practice and should not be delegated to assistive personnel.

A. A newborn has an Apgar score of 7 at 5 min after birth. B. A newborn has respiratory distress and requires oxygen. C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth. D. A newborn receives a heel stick on the outer aspect of the heel.

Correct Answer is C

Explanation

Answer: C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth.

Rationale:

A. A newborn has an Apgar score of 7 at 5 min after birth:
An Apgar score of 7 is within the acceptable range and does not indicate an adverse event or require an incident report. This score reflects a newborn transitioning well to extrauterine life with only mild adjustments needed.

B. A newborn has respiratory distress and requires oxygen:
While respiratory distress requires prompt intervention, it can be an expected complication in some neonates. Administering oxygen in this context is an appropriate clinical response, not a reportable incident.

C. A newborn receives erythromycin ophthalmic ointment 4 hr after birth:
Erythromycin should be administered within 1 to 2 hours after birth to prevent ophthalmia neonatorum. A 4-hour delay exceeds this timeframe and poses a potential risk to the infant’s health, qualifying as a deviation from standard protocol that warrants an incident report.

D. A newborn receives a heel stick on the outer aspect of the heel:
Performing a heel stick on the outer aspect of the heel is the correct location to avoid nerve and bone injury. This is a safe and standard practice and does not require an incident report.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is preparing to provide 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

A nurse is caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is C

Explanation

A nurse in the newborn nursery is providing care for four newborns. For which of the following events should the nurse plan to complete an incident report?

Correct Answer is C

Explanation

A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

A nurse is reinforcing teaching with a group of newly licensed nurses about client rights. Which of the following scenarios should the nurse include as an example of a client rights violation for which a nurse should intervene? (Select all that apply).

A nurse is reinforcing teaching with a group of assistive personnel about fire evacuation procedures. Which of the following information the nurse includes in the teaching?

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following cleansing agents should the nurse use?

A nurse in a long-term care facility is reviewing the facility documentation policies with a newly licensed nurse. Which of the following abbreviations should the nurse remind the newly licensed nurse to use when documenting care?

A nurse is caring for an older adult client who has a new diagnosis of cancer. Which of the following client statements indicates the nurse should act as a client advocate?