The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?
“The client status is deteriorating. I feel you should come now.”.
“The client has hypoxemia after 10 minutes on a rebreather mask.”.
“The PaO2 is 55, PaCO2 is 90, HCO3 is 26.”.
“The client has a history of chronic obstructive pulmonary disease and was admitted with pneumonia.”.
The Correct Answer is B
The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.
The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.
Choice A is wrong because it is not a clear statement of the situation.
It is vague and does not provide specific information about the client’s condition or vital signs.
It also expresses the nurse’s feeling rather than an objective assessment.
Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.
It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.
Choice D is wrong because it is part of the Background component of SBAR, not the Situation.
It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.
Normal ranges for blood gas analysis are:
- PaO2: 80-100 mmHg
- PaCO2: 35-45 mmHg
- HCO3: 22-26 mEq/L
Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.
This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.
Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.
Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.
Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.
Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.
Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to
1.2 mg/dL.
Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.
The nurse should monitor these levels and report any abnormalities to the health care provider.
Correct Answer is ["A","D","E"]
Explanation
These choices validate the client with acute pain because they are signs of a sympathetic nervous system response to pain. Acute pain is a sudden and usually sharp sensation that indicates tissue damage or injury.
Choice B is wrong because dilated pupils are not a sign of acute pain. Pupils may dilate in response to fear, excitement, or drugs.
Choice C is wrong because constricted pupils are not a sign of acute pain. Pupils may constrict in response to bright light, drugs, or brain damage.
Choice F is wrong because decreased respirations are not a sign of acute pain. Respirations may decrease in response to relaxation, drugs, or respiratory depression.
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