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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Respiratory acidosis: Respiratory acidosis is characterized by a high PaCO2 level due to hypoventilation or impaired lung function, which is not reflected in this ABG result. The pH of 7.30 indicates acidosis, but the normal PaCO2 of 40 mmHg suggests it is not respiratory in nature.
B. Respiratory alkalosis: Respiratory alkalosis involves a decrease in PaCO2, which is not present here. The PaCO2 of 40 mmHg is within normal range, ruling out this possibility.
C. Metabolic acidosis, uncompensated: The low HCO3- of 20 mEq/L and the pH of 7.30 indicate metabolic acidosis. Since there is no compensation by the lungs (i.e., PaCO2 is not lowered), this is considered uncompensated metabolic acidosis.
D. Metabolic alkalosis, uncompensated: Metabolic alkalosis would involve an elevated HCO3- level and a higher pH, which is not seen in this case. The HCO3- is low, supporting metabolic acidosis, not alkalosis.

A. Thoracentesis B. Ultrasound C. Focused assessment with sonography in trauma (FAST) D. Chest x-ray E. Pleural cavity decompression via needle aspiration

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

Explanation

A. Thoracentesis: Thoracentesis may be ordered if there is suspected pleural effusion or hemothorax following thoracic trauma. It allows for both diagnostic and therapeutic removal of fluid or blood from the pleural space and helps assess the extent of internal injury.
B. Ultrasound: Ultrasound is a non-invasive tool used to quickly assess thoracic structures such as the pleura and pericardium. It helps detect hemothorax, pneumothorax, or pericardial effusion, and is commonly used in emergency settings for rapid diagnosis.
C. Focused assessment with sonography in trauma (FAST): FAST is a rapid bedside ultrasound exam used to detect free fluid (blood) in the thoracic or abdominal cavity. In trauma cases, it helps quickly identify life-threatening internal bleeding or organ injury, making it a critical diagnostic tool.
D. Chest x-ray: A chest x-ray is a standard imaging technique used to evaluate thoracic injuries. It can reveal fractures, pneumothorax, hemothorax, and other abnormalities in the chest cavity, providing a clear view of the extent of injury.
E. Pleural cavity decompression via needle aspiration: Needle aspiration is a therapeutic procedure rather than a diagnostic tool. It is used in emergencies to relieve a tension pneumothorax, not to assess or diagnose thoracic injury. Therefore, it is not anticipated as a diagnostic measure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's arterial blood gas (ABG) results show a pH of 7.30, PaCO2 of 40 mmHg, HCO3- of 20 mEq/L. These findings indicate which of the following conditions?

Correct Answer is C

Explanation

A nurse is caring for a client who presents to the hospital with manifestations of a thoracic injury. Which of the following diagnostic tools would the nurse anticipate the health care provider to order? (Select all that apply.) (Select All that Apply.)

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

Explanation

A nurse is caring for a client on a medical surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse should first ______due to the client's_____

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A nurse is caring for a client who has a pulmonary embolism. The nurse should identify that the release of inflammatory mediators leads to which of the following pathologic findings?

A nurse is reviewing a client's laboratory results and sees that their hemoglobin A1C is 9%. Which of the following statements from the nurse is appropriate?

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