A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

A young adult client admitted for acute glomerulonephritis following a viral infection

A dependent adult admitted for the treatment of a spiral fracture

A young adult client admitted for asthma and has track marks that may indicate IV drug abuse

An emancipated minor who has acute appendicitis and wants to leave the facility without treatment

Answer and Explanation

The Correct Answer is B

Rationale:

A. A young adult client admitted for acute glomerulonephritis following a viral infection does not indicate a mandatory report situation.

B. A dependent adult admitted for the treatment of a spiral fracture suggests potential abuse or neglect. As mandated reporters, nurses are required to report suspicions of abuse or neglect to the appropriate authorities.

C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse does not necessarily require mandatory reporting unless there is evidence of abuse or harm that needs to be reported.

D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment may raise concerns about the minor's capacity to make decisions, but it does not automatically necessitate reporting to an outside agency.

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Correct Answer is D

Explanation

Rationale:

A. "There are no provider's prescriptions available." is related to background information but does not describe the current situation of the client.

B. "The client was found unconscious on the floor in her home." provides information about the situation but not the current clinical background.

C. "The client should be seen by a neurologist." is a recommendation for further action and should be included in the "Recommendation" section of SBAR, not "Background."

D. "The client is disoriented. Pupils are slow to respond to light." provides relevant background information about the client's current condition, which is necessary for the SBAR "Background" step.

A. Providing a back rub to a client who has right-sided paralysis B. Transporting a client who experienced a stroke 72 hr ago to the radiology department C. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm D. Removing and cleaning the cannula of a client who has a new tracheostomy

Correct Answer is D

Explanation

Rationale:

A. Providing a back rub can be done by an AP, as it does not require specialized nursing skills.

B. Transporting a client is an appropriate task for an AP if the client is stable.

C. Performing oral hygiene for a postoperative client can be managed by an AP with supervision.

D. Removing and cleaning the cannula of a new tracheostomy requires specific skills and knowledge that only a licensed nurse should perform to avoid complications.

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A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step?

Correct Answer is D

Explanation

A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?

Correct Answer is D

Explanation

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