A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?
Provider notified of client’s back pain
Request prescription for opioid medication for pain relief
Client is grimacing due to pain
Client admitted with ruptured disc at L5
The Correct Answer is C
Choice A reason: This statement belongs to the recommendation component, as it describes an action that the nurse has taken or suggests to take regarding the client's care.
Choice B reason: This statement also belongs to the recommendation component, as it expresses a need or a request for the client's treatment.
Choice C reason: This statement belongs to the situation component, as it summarizes the current problem or issue that the client is facing.
Choice D reason: This statement belongs to the background component, as it provides relevant information about the client's medical history or diagnosis.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.
Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Correct Answer is D
Explanation
Choice A reason: Eddie Bernice Johnson is not the founder of the American Red Cross, but rather a contemporary politician and nurse. She is the first registered nurse elected to the United States Congress, where she represents Texas's 30th congressional district.
Choice B reason: Florence Nightingale is not the founder of the American Red Cross, but rather the founder of modern nursing. She is known for her pioneering work in nursing education, research, and reform, especially during the Crimean War, where she improved the sanitary conditions and reduced the mortality rate of wounded soldiers.
Choice C reason: Dorothea Dix is not the founder of the American Red Cross, but rather a social reformer and advocate for the mentally ill. She is known for her efforts to improve the treatment and care of the mentally ill in the United States and Europe, and for organizing nurses during the American Civil War.
Choice D reason: Clara Barton is the founder of the American Red Cross, as well as a nurse and humanitarian. She is known for her service as a nurse during the American Civil War, where she tended to the wounded on the battlefield and distributed supplies. She also founded the American Red Cross in 1881, after learning of the International Red Cross in Switzerland, and led the organization for 23 years.
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