The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

The SBAR is used to organize and standardize communication.

The SBAR is used to help Physical Therapy determine the client’s abilities.

The SBAR is used to help physicians with diagnoses.

The SBAR is used to educate clients about their disease processes.

Answer and Explanation

The Correct Answer is A

The SBAR is used to organize and standardize communication between members of the health care team about a patient’s condition. It is an acronym for Situation, Background, Assessment, and Recommendation.

Choice B is wrong because the SBAR is not used to help Physical Therapy determine the client’s abilities.

Physical Therapy may use other tools or methods to assess the client’s functional status.

Choice C is wrong because the SBAR is not used to help physicians with diagnoses.

The SBAR is a communication tool, not a diagnostic tool.

Physicians may use other sources of information or tests to make diagnoses.

Choice D is wrong because the SBAR is not used to educate clients about their disease processes.

The SBAR is a tool for interprofessional communication, not for patient education.

Clients may receive education from other sources or materials.

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Correct Answer is C

Explanation

his intervention can help prevent pressure ulcers by reducing the amount of pressure on bony prominences and promoting blood circulation to the skin.

Choice A is wrong because placing the patient in a side-lying position only can increase the risk of skin breakdown by limiting the patient’s mobility and exposing the same areas to pressure. The patient should be repositioned frequently and encouraged to change positions if able.

Choice B is wrong because massaging bony prominences can cause tissue damage and increase the risk of skin breakdown by impairing blood flow to the area. Massaging should be avoided over bony prominences and areas of redness.

Choice D is wrong because keeping the head of the bed elevated higher than 30 degrees can cause shearing forces on the skin, which can lead to skin breakdown. The head of the bed should be kept at the lowest degree of elevation possible.

Choice E is wrong because inspecting skin every shift is not enough for a patient at risk for impaired skin integrity. The skin should be inspected at least every 2 hours or more frequently depending on the patient’s condition. Early detection of skin changes can help prevent further damage and promote healing.

Normal ranges for skin integrity are:

• Skin color: consistent with ethnicity and genetic background, no pallor, cyanosis, or jaundice.

• Skin moisture: dry to touch, no excessive perspiration or dryness. • Skin texture: smooth, soft, intact, with even surface.

• Skin temperature: warm to touch, no hyperthermia or hypothermia. • Skin turgor: elastic, returns to original shape after being pinched. • Skin integrity: no lesions, wounds, abrasions, or ulcers.

A. Stimulates bone marrow production of red blood cells. B. Is given to all people with anemia. C. Is given for iron deficiency anemia. D. Stimulates bone marrow production of white blood cells.

Correct Answer is A

Explanation

This helps increase the oxygen-carrying capacity of the blood and corrects anemia.

Choice B is wrong because erythropoietin is not given to all people with anemia. It is only used for certain types of anemia, such as those caused by chronic kidney disease or chemotherapy.

Choice C is wrong because erythropoietin is not given for iron deficiency anemia. Iron deficiency anemia is treated with iron supplements and dietary changes.

Choice D is wrong because erythropoietin does not stimulate bone marrow production of white blood cells. White blood cells are involved in immune responses and are produced by different growth factors.

Question 22.

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The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

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Naxlex Comprehensive Predictor Exams

The RN identifies that a client is at risk for impaired skin integrity. Which interventions should the nurse add to this client’s plan of care?

Correct Answer is C

Explanation

A person with anemia is prescribed erythropoietin subcutaneously. The nurse knows that erythropoietin:

Correct Answer is A

Explanation

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

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