The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements?

1. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client."

2. "The client is deteriorating, and I'm afraid the client is going to arrest."

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)."

4. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask."

2,4,3,1

3.4.2.1

4.3.2.1

3.4.1.2

Answer and Explanation

The Correct Answer is A

1. "The client is deteriorating, and I'm afraid the client is going to arrest." This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action. In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1).

2. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask." This statement elaborates on the clinical findings and symptoms, giving the HCP a better understanding of the patient's condition and how it is affecting their overall stability. The details about the patient's physical state, such as skin condition and oxygen saturation, highlight the critical nature of the situation.

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)." This provides the background information, including the patient's vital signs, which is critical for the HCP to evaluate the situation. Clear communication of vital signs establishes a baseline for the HCP to assess the urgency of the clinical scenario and informs potential interventions.

4. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client." This statement summarizes the recommendation, clearly indicating the action the nurse believes should be taken based on the assessment. It conveys the need for immediate evaluation and care in a higher-acuity setting, ensuring that the HCP understands the recommended next steps in the patient’s management.

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Correct Answer is A

Explanation

A. Wash the area of the puncture thoroughly with soap and water: The first action the nurse should take after a needlestick injury is to immediately wash the area with soap and water. This is crucial for minimizing the risk of infection and exposure to potentially infectious materials. Prompt cleaning of the puncture site is essential in reducing the risk of transmission of bloodborne pathogens.

B. Notify employee health services: While notifying employee health services is important for follow-up care and evaluation, it should be done after the initial wound care has been performed. Immediate action should focus on cleaning the injury first.

C. Complete an incident report: Completing an incident report is a necessary step for documentation and accountability in the healthcare setting. However, it should be done after the immediate first aid for the needlestick injury has been addressed.

D. Report the incident to the charge nurse: Reporting the incident to the charge nurse is important for ensuring appropriate follow-up and support, but the priority should be to address the injury first. The nurse should take care of the puncture wound before notifying others about the incident.

A. Twist at the waist when she moves an object to one side. B. Bend at the knees when picking up an object. C. Hold an object away from her body as she lifts it. D. Relax her abdominal muscles when she lifts an object.

Correct Answer is B

Explanation

A. Twist at the waist when she moves an object to one side: Twisting at the waist can place excessive strain on the lower back and increase the risk of injury. Instead, the client should pivot her whole body to move an object, which helps maintain spinal alignment and reduces strain.

B. Bend at the knees when picking up an object: This instruction is crucial for preventing back strain. Bending at the knees allows the client to use her legs' strength to lift the object rather than putting pressure on the back. This technique helps protect the spine and promotes safe lifting practices.

C. Hold an object away from her body as she lifts it: Holding an object away from the body increases leverage and strain on the back muscles. The client should keep the object close to her body while lifting to maintain better balance and reduce the risk of injury.

D. Relax her abdominal muscles when she lifts an object: Engaging the abdominal muscles provides support to the spine during lifting. Relaxing the abdominal muscles can lead to a lack of core stability, increasing the risk of back injury. The client should be encouraged to engage her core muscles while lifting.

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Naxlex Comprehensive Predictor Exams

A nurse accidentally sticks her hand with a syringe after administering an IM injection to a client. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Which of the following is a benefit of negative pressure wound therapy (NPWT) for skin wounds?

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?

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