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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Informed consent:

While informed consent documents provide information about the proposed surgical procedure, they typically do not include information about organ donation. Informed consent focuses on the risks, benefits, and alternatives of the procedure being performed, as well as the client's agreement to undergo the procedure.

B) Advance directives:

Advance directives, such as a living will or healthcare proxy, can contain information about a client's preferences regarding organ donation. These documents specify the client's wishes regarding medical interventions, including organ donation, in the event that they become incapacitated and unable to make decisions for themselves. Advance directives guide healthcare providers and family members in honoring the client's preferences regarding end-of-life care and organ donation.

C) Do-not-resuscitate order:

A do-not-resuscitate (DNR) order instructs healthcare providers not to perform cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. While organ donation preferences may be discussed in the context of end-of-life care decisions, a DNR order specifically pertains to resuscitative measures and does not provide information about organ donation.

D) Provider's prescription:

A provider's prescription typically pertains to specific medications or treatments ordered by the healthcare provider for the client's care. It does not typically contain information about organ donation. Organ donation preferences are typically documented in advance directives or other specific forms related to donation programs.

A. Initiate oxygen therapy via nasal cannula for a client who has COPD. B. Initiate a 24-hr urine collection for a client who has end-stage kidney disease. C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus. D. Change the dressing for a client who has a decubitus ulcer.

Correct Answer is A

Explanation

A) Initiate oxygen therapy via nasal cannula for a client who has COPD:

Clients with chronic obstructive pulmonary disease (COPD) often have impaired gas exchange and may experience acute exacerbations requiring oxygen therapy to improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical intervention to address hypoxemia and prevent complications such as respiratory failure. Therefore, initiating oxygen therapy for a client with COPD is the highest priority among the options provided.

B) Initiate a 24-hr urine collection for a client who has end-stage kidney disease:

Initiating a 24-hour urine collection is an important nursing task for clients with end-stage kidney disease to monitor renal function and assess urine output. However, compared to the immediate need for oxygen therapy in a client with COPD, starting a urine collection is a lower priority and can be scheduled once the client's respiratory needs are addressed.

C) Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus:

Administering antibiotics for a client with methicillin-resistant Staphylococcus aureus (MRSA) infection is important to control the spread of infection and prevent complications. However, unless the client's condition is critically unstable or the antibiotic administration is time-sensitive, addressing oxygenation needs for a client with COPD takes precedence due to the potential for respiratory compromise and hypoxemia.

D) Change the dressing for a client who has a decubitus ulcer:

Changing dressings for clients with decubitus ulcers is essential for wound care management and prevention of infection. While maintaining skin integrity is important, addressing respiratory distress in a client with COPD is a higher priority to ensure adequate oxygenation and prevent respiratory compromise.

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 a client who is scheduled for surgery. While reviewing the client's medical record, the nurse notes the client is an organ donor. Which of the following documents provides information about organ donation?

Correct Answer is B

Explanation

A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a stage III pressure ulcer and requires a dressing change. Which of the following steps should the nurse take first?

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 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 assisting with the care of a client who is experiencing a cardiac arrest. Which of the following tasks should the nurse assign to an assistive personnel?

A nurse is caring for a group of clients on a medical-surgical unit. The nurse should ensure that the client has signed an informed consent form prior to which of the following procedures? (Select all that apply)

A nurse is caring for a client who has a terminal illness and wishes to discuss hospice care. Which of the following statements by the nurse demonstrates veracity?

A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the plan of care for a child whose parents refuse to accept the medical treatment prescribed by the provider. Which of the following actions should the nurse plan to take first to address this ethical dilemma?