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 A

Explanation

Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.

Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.

Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.

Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.

It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.

Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.

A. 3+ palpable pedal pulses below the affected injury site. B. Full range of motion at the site of injury. C. Sanguineous drainage at the site of injury. D. Localized warmth at the site of injury.

Correct Answer is D

Explanation

Localized warmth at the site of injury is a sign of localized inflammation of the tissues, which is a response to tissue damage caused by an ankle injury. Localized inflammation involves changes in blood flow, vessel permeability, and leukocyte migration to the site of injury. Heat is one of the five classic signs of acute local inflammation, along with redness, swelling, pain, and loss of function.

Choice A is wrong because 3+ palpable pedal pulses below the affected injury site indicate normal blood flow to the foot and do not reflect inflammation.

Choice B is wrong because full range of motion at the site of injury is unlikely in the presence of inflammation, which usually causes pain and loss of function.

Choice C is wrong because sanguineous drainage at the site of injury is a sign of bleeding, not inflammation.

Inflammation may cause fluid leakage from blood vessels, but this fluid is usually clear or yellowish, not bloody.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues?

Correct Answer is D

Explanation

A client sees his primary care physician for complaints of fatigue. Bloodwork shows the client is anemic. Upon physical assessment, what signs would the provider expect to see? (Select all that apply)

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