A nurse is assessing a client who is 1 day postoperative following a total knee arthroplasty. The client is scheduled for physical therapy in 45 min. Which of the following questions should the nurse ask first?

“Have you used an incentive spirometer today?"

"What is your current pain level on a scale of 0 to 10?"

"Have you informed your family of your physical therapy schedule?"

"Would you like to bathe before or after physical therapy?"

Answer and Explanation

The Correct Answer is B

A.   While the use of an incentive spirometer is crucial for preventing respiratory complications such as atelectasis, this question is less urgent in the context of preparing for physical therapy. The immediate priority should be to assess the client’s readiness for physical therapy, including their pain level and comfort, rather than focusing on the spirometer use.
B.   Assessing the client's current pain level is crucial because pain management directly impacts the
client’s ability to participate in physical therapy effectively. Ensuring that the client’s pain is adequately controlled will help in achieving a more successful therapy session and in preventing discomfort or additional complications during the therapy.
C.   While informing family members about the physical therapy schedule might be important for planning family support and involvement, it is not as urgent as ensuring the client is physically ready for the therapy session.
D.   This question addresses personal preference regarding bathing but is not as critical as assessing the client’s pain level or immediate readiness for physical therapy. While personal hygiene is important, it should not take precedence over addressing pain management and ensuring the client is prepared for physical therapy.

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Correct Answer is C

Explanation

A. The client’s code status (e.g., full code, do not resuscitate) is crucial information for any healthcare provider, especially when transferring care. However, this detail is typically included in the Situation or Assessment sections rather than the Background. It is important to communicate the code status clearly, but it is not part of the historical or contextual information provided in the Background section.
B. While the client's name is important for identification, it is usually not detailed in the Background section. Instead, it is generally included at the beginning of the report or in the Situation section where initial identification and immediate concerns are presented.
C. Information about a prescribed consultation (e.g., a referral to a specialist) falls under the Background section of the SBAR. This part of the report should include pertinent historical details and context, such as any previous consultations or significant events that have impacted the client’s current condition.
D. Vital signs are crucial for assessing the current status of the client but are usually included in the Assessment section of the SBAR. This section provides a summary of the client’s current condition, including vital signs, lab results, and other relevant clinical data.

A. Two staff members have called to say they will be absent. B. Transport assistance is unavailable to take a client to occupational therapy. C. The emergency department nurse is waiting to give report on a new admission D. A nurse on the previous shift wrote an incident report about a medication error.

Correct Answer is C

Explanation

A. Staffing issues are important as they can affect the workload and safety of the unit. However, the immediate concern is usually related to direct patient care. This situation should be addressed promptly to ensure coverage and proper delegation of tasks, but it is not the most urgent concern compared to issues directly affecting patient safety or emergency situations.
B. While this issue affects the logistical aspects of patient care, it is less critical compared to urgent patient care needs or emergencies. Arranging alternative transport solutions or rescheduling the therapy session should be addressed, but it is not as immediate as other concerns.
C. This situation should be addressed first because timely handoff of patient information is crucial for continuity of care. The new admission could require immediate attention, and a delay in receiving the report could impact patient care.
D. While an incident report about a medication error is significant and should be reviewed and addressed, it does not require immediate action in the same way that ensuring patient care continuity does. The charge nurse should review the incident report and follow up as necessary, but it is not as urgent as the need to receive a report on a new admission from the emergency department.

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A nurse is assessing a client who is 1 day postoperative following a total knee arthroplasty. The client is scheduled for physical therapy in 45 min. Which of the following questions should the nurse ask first?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is C

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