A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.

Provide a brief description of the client’s diagnosis.

Discuss suggestions for continuing the client’s care.

State the client’s most recent vital signs.

Review the client’s pertinent medical history.

Answer and Explanation

The Correct Answer is B

The nurse should give report using the SBAR Communication tool in the following order: Situation, Background, Assessment, Recommendation. This tool provides a framework for communication between members of the health care team about a patient’s condition. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team.

Choice A is wrong because it is part of the Background section of the SBAR tool, which comes after the Situation section.

Choice C is wrong because it is part of the Assessment section of the SBAR tool, which comes after the Background section.

Choice D is wrong because it is also part of the Background section of the SBAR tool, which comes after the Situation section.

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Correct Answer is C

Explanation

The correct answer is choice C. Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.

Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.

Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.

Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.

A. Report of pain as 6 on a scale of 0 to 10. B. Pulses 2+ distal to the client’s fracture. C. Petechiae over the client’s chest. D. Bruising around the fracture site.

Correct Answer is C

Explanation

This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.

Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.

Pain is a common symptom of many conditions and injuries.

Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.

Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.

Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.

Petechiae are small red or purple spots on the skin caused by bleeding under the skin.

They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.

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A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool. Identify the order in which the nurse should give report.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering the inactivated influenza vaccine to a group of clients at a health clinic. The nurse should recognize that which of the following conditions is a contraindication for this vaccine?

Correct Answer is C

Explanation

A nurse is caring for a client who has a compound fracture of the femur. Which of the following findings should the nurse report to the provider as a manifestation of a fat embolism?

Correct Answer is C

Explanation

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A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.