An emergency department nurse is providing handoff communication using SBAR (situation, background, assessment, recommendations) to the nurse accepting a client in the intensive care unit. The emergency department nurse reports that the client will require a suction set up for gastric tube drainage and will need an endoscopy performed. Which of the following parts of the SBAR report is the nurse communicating?
S-Situation
R-Recommendations
B-Background
A-Assessment
The Correct Answer is B
A. S–Situation: The situation includes immediate information about why the client is being transferred or receiving care, such as current symptoms, diagnosis, or presenting complaint. It does not include upcoming procedures or equipment needs.
B. R–Recommendations: Recommendations include what actions or interventions are needed next, such as upcoming tests, procedures, or equipment setup. Mentioning the need for a suction setup and an endoscopy reflects planning for ongoing care and falls under this category.
C. B–Background: Background refers to the client's medical history, diagnosis, and events leading up to the current situation. It gives context but does not include plans for future care.
D. A–Assessment: Assessment includes clinical findings, vital signs, laboratory results, and how the client is currently presenting. It focuses on objective and subjective data, not future recommendations or equipment planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Decreased visual acuity: Decreased visual acuity is a significant factor in head injuries in older adults. Poor vision increases the likelihood of falls and accidents, as individuals are less able to detect obstacles or changes in their environment, leading to an increased risk of injury, including head trauma.
B. Motor vehicle crashes: While motor vehicle accidents can lead to head injuries, they are not as prevalent in older adults compared to other causes such as falls. Older adults are more likely to sustain head injuries from falls rather than from motor vehicle crashes, especially since they may not be as active in driving or are more cautious on the road.
C. Polypharmacy: Polypharmacy, or the use of multiple medications, is a common issue in older adults and can significantly contribute to the risk of falls and head injuries. Certain medications, such as sedatives, antihypertensives, and medications affecting balance or cognition, can increase the risk of dizziness, confusion, and falls, leading to head trauma.
D. Weakness: Muscle weakness, particularly in the lower extremities, is common in older adults and increases the risk of falls. Weakness can impair balance and coordination, making it harder for individuals to prevent falls or recover from them, resulting in head injuries.
E. Chronic hypertension: While chronic hypertension is a risk factor for cardiovascular events such as stroke, it is not a direct cause of head injuries in older adults. Hypertension may contribute to falls indirectly by affecting the ability to maintain balance due to related health complications, but it is not a primary cause of head injuries.
F. Previous military experience: Military experience is not a typical risk factor for head injuries in older adults. Although previous trauma or combat exposure could result in earlier injuries, it is not a common cause of head injuries in older adults compared to other factors like falls, medication use, or weakness.
Correct Answer is C
Explanation
A. The client who is recovering from a recent illness that caused vomiting and dehydration: Although recent illness can increase the risk of various heart conditions, it does not place the client at the highest risk for developing atrial flutter compared to those with established cardiovascular disease.
B. The client whose mother and uncle were diagnosed with this same condition: Family history can increase the risk of atrial flutter, but it is less of a risk factor than existing heart disease.
C. The client who had a myocardial infarction and required stent placement: This client is at the highest risk due to the structural and electrical changes in the heart that occur following a myocardial infarction, making them more prone to atrial flutter.
D. The client who is out of work and has been experiencing increased stress: While stress can contribute to heart conditions, it is not a significant direct risk factor for atrial flutter when compared to prior heart events like a myocardial infarction.
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