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 D

Explanation

Withholding food and oral fluids until intestinal mobility has returned. This is because the client may have postoperative ileus (POI), which is a reduction of gastrointestinal motility after abdominal surgery. POI is characterized by abdominal distension, lack of bowel sounds, accumulation of gas and fluids in the bowel, and delayed passage of flatus and stools.

Giving food and fluids to a client with POI may worsen the condition and cause complications.

Choice A is wrong because high fat foods may slow down GI motility and increase the risk of constipation.

Choice B is wrong because solid food intake may also aggravate POI and cause abdominal discomfort.

Choice C is wrong because fiber intake may increase gas production and distension in the bowel. The nurse should auscultate the abdomen for bowel sounds, and if they are present, or the client reports passing flatus, clear fluids can commence, and aperients can be administered. However, bowel sounds are not a reliable indicator of the end of POI, as they may not be associated with the time of first flatus.

Therefore, withholding food and oral fluids until intestinal mobility has returned is the most appropriate action by the nurse.

A. Investigate further to confirm the suspicion. B. Report the findings. C. Provide the client with a crisis hotline number. D. Discuss respite care with the client’s family.

Correct Answer is B

Explanation

The nurse has a legal and ethical obligation to report any suspected abuse of a vulnerable client, such as an older adult. Reporting the findings is the first action the nurse should take to protect the client and initiate an investigation by the appropriate authorities.

Choice A is wrong because investigating further to confirm the suspicion is not within the nurse’s scope of practice and could delay the reporting process.

Choice C is wrong because providing the client with a crisis hotline number is not enough to ensure the client’s safety and well-being.

The client might not be able to access the hotline or might be afraid to use it.

Choice D is wrong because discussing respite care with the client’s family is not appropriate at this stage.

The nurse should not assume that the family member is willing or able to provide adequate care for the client.

Respite care might be an option after the abuse is reported and investigated.

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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 nurse is conducting an assessment on a client who is 36 hours postoperative following an appendectomy. During the assessment, the nurse is unable to hear any bowel sounds. The client denies passing flatus (gas). Given this information, which action is most appropriate by the nurse?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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