What is the correct term for the nursing action of deciding that a nonverbal patient who just had surgery is in pain and administering an analgesic, based on the observation that the patient moans with position changes, the hands are clenched, and the skin is very sweaty?

Choice A reason: This is an incorrect choice because the nurse requests that the primary health care provider examines the patient is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The nurse's request is part of the “R”, which stands for recommendation, which is the action that the nurse suggests or requests.

Choice B reason: This is the correct choice because the patient has a fractured right leg with a cast that was applied 2 days ago is the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's fracture and cast are part of the patient's background that the nurse should share with the primary health care provider.

Choice C reason: This is an incorrect choice because the patient’s toes are cool and pale and the patient reports that the foot feels numb is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's toes and foot are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

Choice D reason: This is an incorrect choice because the patient is reporting severe pain 1 hour after pain medication was given is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's pain and medication are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.

Choice A reason: This is an incorrect choice because calling the operator to activate the fire alarm is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Calling the operator to activate the fire alarm is an important action to alert the fire department and the other staff and patients, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before calling for help.

Choice B reason: This is an incorrect choice because closing the door to contain the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Closing the door to contain the fire is a helpful action to prevent the fire from spreading to other areas, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before containing the fire.

Choice C reason: This is an incorrect choice because utilizing a fire extinguisher to put out the fire is not the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Utilizing a fire extinguisher to put out the fire is a possible action to control the fire, but it is not the most urgent or priority action. The nurse should first ensure the safety of the patient and themselves before attempting to extinguish the fire.

Choice D reason: This is the correct choice because removing the patient to a safe area is the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire. Removing the patient to a safe area is the most urgent and priority action to protect the patient from the fire, smoke, and heat. The nurse should first assess the patient for any injuries or burns, and then move the patient to a safe and clear location away from the fire.