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.
The Correct Answer is C,D,A,B
A. The statement detailing the temperature of 39.5 degrees C (103.1 degrees F) represents the Assessment (A) phase, where the nurse shares the objective physical findings and clinical measurements gathered during the client evaluation. This logically follows the background context.
B. Requesting a prescription for a sputum culture represents the Recommendation (R) phase, which is the final step of the communication framework. In this phase, the nurse proposes a specific action or intervention to the provider to address the identified problem.
C. The statement regarding the report of increasing shortness of breath represents the Situation (S) phase, which must be presented first. This step establishes the immediate reason for the communication and states the current clinical problem.
D. The statement noting that the client has COPD represents the Background (B) phase, which is the second step. This provides the essential clinical history and context surrounding the client to help the provider understand the underlying factors related to the current situation.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
Correct Answer is A
Explanation
A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.
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