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 ["A","B","D","E"]

Explanation

Explanation:

A. "We use an automated dispensing device to track the use of controlled substances."

This is a valid statement. Automated dispensing devices (ADDs) help track the use of controlled substances by requiring users to log in, record transactions, and provide an audit trail of medication access.

B. "You are required to have a second nurse witness disposal of a controlled substance."

Having a second nurse witness disposal of controlled substances is a common practice to ensure accountability and prevent diversion. This statement aligns with safety protocols.

C. “If a client refuses a medication, you can place it in your pocket to administer later."

This statement is incorrect and potentially dangerous. Controlled substances should never be pocketed or carried around for later administration, as this increases the risk of diversion and compromises medication safety.

D. "Activities of the automated dispensing machine will be reviewed periodically."

Reviewing the activities of the automated dispensing machine is an essential part of medication safety and helps detect any discrepancies or irregularities in medication access and administration.

E. "We count the amount of a controlled substance available before removal from a medication drawer."

Counting the amount of controlled substances before removal from a medication drawer is a standard procedure to ensure accurate inventory management and detect any discrepancies or losses promptly.

A. A 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle B. A 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows. C. A 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water D. A 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself.

Correct Answer is D

Explanation

Explanation:

A. A 6-year-old child with a spiral fracture of the tibia and fibula, reportedly occurring while riding a bicycle:

While a spiral fracture can be concerning, it is also a common injury seen in children due to falls or accidents during physical activities such as riding a bicycle. Without further evidence or suspicion, this may not immediately indicate physical abuse.

B. A 14-month-old toddler reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:

Bruises on bony prominences can be common in toddlers who are learning to walk and explore their environment. These bruises are often seen on areas such as the lower legs and elbows. Without additional concerning signs or patterns, this may not indicate physical abuse.

C. A 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:

Near drowning incidents can occur accidentally, especially in curious and mobile infants who may explore their surroundings. While this is a serious event, it does not necessarily suggest physical abuse unless there are other suspicious findings or a history of non-accidental injuries.

D. A 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:

Scalding burns, especially over sensitive areas like the face and chest, can raise concerns about physical abuse, especially when the reported mechanism of injury (spilling a cup of tea) seems inconsistent or disproportionate to the severity of the burns. The pattern and location of burns may not align with accidental spillage, leading to suspicion of abuse.

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Naxlex Comprehensive Predictor Exams

A newly hired nurse asks a charge nurse what safety measures are in place to prevent diversion of controlled substances on the unit. Which of the following statements should the charge nurse make?(Select All that Apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

Correct Answer is D

Explanation

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

A nurse is contributing to the plan of care for a client who has had HIV for 10 years and is at the end of life. Which of the following interventions should the nurse recommend?

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.)

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first?

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 preparing to delegate tasks to an assistive personnel (AP). The nurse should identify which of the following as one of the five rights of delegation?

A nurse is researching data about best practice for reducing medication errors on a surgical unit. Which of the following steps of evidence based practice (EBP) is the nurse taking?

A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?