A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Medical condition

Treatment

Vital signs

List of medications

Answer and Explanation

The Correct Answer is A

Explanation:

A. Medical condition:

Including the client's medical condition in the Situation component of the ISBARR communication tool is important because it provides an overview of the client's health status. This may include a brief description of the primary diagnosis, current symptoms, or any significant changes in the client's condition since the last shift. It helps the receiving nurse understand the context and urgency of the report.

B. Treatment:

While treatment information is crucial for providing comprehensive care to the client, it is typically included in the Background or Assessment components of the ISBARR communication tool. The Situation component focuses on summarizing the client's current status rather than detailing specific treatments or interventions.

C. Vital signs:

Vital signs, such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, are essential clinical data. However, they are usually included in the Assessment component of the ISBARR communication tool, where the nurse provides a detailed assessment of the client's physiological parameters and trends.

D. List of medications:

Similar to treatment information, a list of medications is typically included in the Background or Assessment components of the ISBARR communication tool. It is important for the receiving nurse to know what medications the client is taking, including doses, frequencies, and any recent changes, but this information is more detailed and specific than what is typically included in the Situation component.

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Correct Answer is B

Explanation

Explanation:

A. Material safety data sheets:

Material safety data sheets (MSDS) are documents that provide information about the properties of chemicals and substances, including hazards, handling, storage, and emergency procedures. While MSDS are crucial for ensuring safe handling of materials, they primarily focus on chemical safety and may not provide detailed guidance on specimen collection protocols. Therefore, while MSDS are essential references for safety, they are not the primary source for revising specimen collection protocols.

B. Evidence-based practice:

Evidence-based practice (EBP) involves integrating the best available evidence from research studies, clinical expertise, and patient values and preferences to make informed decisions about patient care. For revising protocols, nurses should rely heavily on evidence-based guidelines and research literature related to specimen collection techniques, safety measures, accuracy, and quality assurance. EBP ensures that protocols are based on the latest scientific evidence, leading to improved patient outcomes and quality of care.

C. Client medical records:

Client medical records contain detailed information about individual patients, including their medical history, diagnoses, treatments, and laboratory results. While medical records are valuable for understanding specific patient needs and conditions, they are not typically used as primary sources for developing or revising unit-wide protocols. However, reviewing medical records may provide insights into specific challenges or issues related to specimen collection for certain patients.

D. Facility policy and procedures:

Facility policy and procedures manuals outline the organization's guidelines, protocols, and standards of practice for various aspects of patient care, including specimen collection. Nurses should refer to facility policies and procedures to understand existing protocols, safety measures, documentation requirements, and quality control processes related to specimen collection. While facility policies are important references, they may need to be updated based on current evidence and best practices, which is where evidence-based practice comes into play.

A. Increased bowel sounds B. Hypertension C. Mottled skin D. Moist mucous membranes

Correct Answer is C

Explanation

Explanation:

A. Increased bowel sounds:

In end-of-life care, clients often experience a decrease in bowel sounds rather than an increase. Bowel sounds may diminish or become absent as the body's systems slow down.

B. Hypertension:

Hypertension is less commonly observed in clients at the end of life. Instead, blood pressure may decrease as the body's overall function declines.

C. Mottled skin:

Mottled skin, characterized by a blotchy or marbled appearance, is a common finding in clients approaching the end of life. It occurs due to changes in peripheral circulation and may indicate decreased perfusion.

D. Moist mucous membranes:

In contrast to moist mucous membranes, clients at the end of life may experience dry mucous membranes. Reduced oral intake and hydration levels can lead to dryness of the mouth and mucous membranes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting research to revise the protocol for specimen collection on their unit. From which of the following sources should the nurse retrieve the information?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?

A charge nurse is discussing evidence-based practice (EBP) and the hierarchy of evidence with a newly licensed nurse. Which of the following examples should the nurse provide when discussing Level I evidence?

A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include?

A nurse is planning to use research and scientific data to improve client care. Which of the following processes is the nurse planning to use?

A nurse is preparing to administer amoxicillin 300 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing an in-service about evidence-based practice (EBP). Which of the following information should the nurse include about peer-reviewed sources of information?

A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)