A newly licensed nurse is giving a change-of-shift report using Introductions, Situation, Background, Assessment, Recommendation (ISBAR) to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the "Background" portion of the report?
"The client has a new prescription for incentive spirometry."
"The client's partner plans to return later today."
"The client has no living family members."
"I initiated a consultation by a nutritionist."
The Correct Answer is C
A. "The client has a new prescription for incentive spirometry.": This statement is more appropriate for the "Assessment" or "Recommendation" section, as it pertains to current treatment plans and interventions rather than the background context of the client's history.
B. "The client's partner plans to return later today.": This information is relevant to the client's social support and engagement but is not critical background information. It may be included in the "Situation" or "Recommendation" sections instead.
C. "The client has no living family members.": This statement is pertinent to the "Background" portion, as it provides important context regarding the client's social situation and support system. Understanding the client's background helps the receiving nurse assess potential psychosocial needs and planning for care.
D. "I initiated a consultation by a nutritionist.": This action relates to ongoing care and assessment of the client's nutritional needs, making it more appropriate for the "Assessment" or "Recommendation" section. It is not part of the historical background needed for effective handoff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. I should get assistance when lifting more than 35 pounds: The recommended guideline for safe lifting is to seek assistance or use mechanical aids when lifting objects heavier than 35 pounds. This helps prevent musculoskeletal injuries, particularly in healthcare settings where lifting and repositioning patients is common.
B. I will twist at my waist when moving an object: Twisting at the waist while lifting or moving objects increases the risk of back strain and injury. Proper body mechanics involve pivoting with the feet rather than twisting the torso to reduce stress on the spine and prevent injury.
C. I should hold objects 1 foot away from my body when I walk: Holding objects away from the body increases strain on the arms, shoulders, and back. Keeping objects close to the body, at waist level, helps maintain balance, reduces muscle fatigue, and minimizes the risk of injury.
D. I will roll my shoulders forward to reduce strain on my back: Rolling the shoulders forward can lead to poor posture and increased back strain. Maintaining a neutral spine, keeping the shoulders relaxed and aligned, and engaging core muscles help reduce the risk of injury when lifting or moving objects.
Correct Answer is A
Explanation
A. "If you accept this assignment today, I will let you choose your assignment tomorrow.": This statement exemplifies smoothing as a conflict resolution strategy. By offering a compromise or incentive, the charge nurse is attempting to reduce tension and create a more favorable situation for the staff nurse, thereby smoothing over the disagreement about the assignment.
B. "Let's just focus on giving out client medications on time.": This statement diverts attention from the conflict but does not actively seek to resolve it. It may minimize the issue temporarily but does not address the underlying disagreement or concern regarding the assignment.
C. "If you don't agree with the assignment, I will have to report your decision to the nursing supervisor.": This statement is confrontational and may escalate the conflict rather than resolve it. It places pressure on the staff nurse and does not foster a collaborative atmosphere for finding a solution.
D. "You have a lot of experience, so I'm sure you're capable of these tasks.": While this statement acknowledges the staff nurse's experience, it may not effectively address the conflict regarding the assignment. It could come across as dismissive of the nurse's concerns rather than facilitating a resolution to the disagreement.
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