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A nurse is providing client report using the Situation, Background, Assessment, Recommendation (SBAR) format. Using SBAR, in which order should the nurse provide the information in the report? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The client's temperature is 39.5° C (103.1° F).

Contact the client's provider for a prescription for a sputum culture.

The client reports increasing shortness of breath.

The client has COPD.

Answer and Explanation

The Correct Answer is D,C,A,B

Rationale

Situation: The client has COPD and is experiencing an acute exacerbation.
Background: The client has a history of COPD and has been experiencing increasing shortness of breath.
Assessment: The client's temperature is 39.5°C (103.1°F) and is experiencing shortness of breath.
Recommendation: Contact the client's provider for a prescription for a sputum culture.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Smoke alarm batteries should be changed at least once a year, not every 2 years, so this statement reflects a misunderstanding of fire safety recommendations.
B. Spraying the extinguisher from side to side at the base of the fire is the correct technique for using a fire extinguisher, indicating the client understands proper fire safety.
C. Attempting to extinguish a fire before calling the fire department can be dangerous; the client should call for help first if the fire is large or spreading.
D. A Class A extinguisher is suitable for ordinary combustibles like wood and paper, but for electrical fires, a Class C extinguisher should be used, indicating a misunderstanding of fire extinguisher types.

A. Inserting an indwelling urinary catheter B. Administering heparin subcutaneously C. Suctioning a client's new tracheostomy D. Classifying a pressure ulcer

Correct Answer is C

Explanation

A. Inserting an indwelling urinary catheter can be performed by licensed practical nurses (LPNs) under the supervision of an RN, so this task does not need to be reassigned.
B. Administering heparin subcutaneously is a task that can be performed by LPNs, so it does not require reassignment to an RN.
C. Suctioning a client's new tracheostomy is a more complex procedure that requires advanced skills and assessment, making it appropriate for an RN rather than an LPN.
D. Classifying a pressure ulcer is a task that can be done by both RNs and LPNs, so it does not need to be reassigned.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reviewing his client care assignments after receiving change-of-shift report. The nurse should notify the charge nurse that which of the following tasks should be reassigned to an RN?

Correct Answer is C

Explanation

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

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