A nurse is planning to use the SBAR communication tool when giving an oncoming shift report. Which of the following statements should the nurse include in the R step?

There are no provider’s prescriptions available.

The client is disoriented.

Let’s review the client’s orders.

The client was found unconscious on the floor in her home.

Answer and Explanation

The Correct Answer is C

Choice A rationale
This statement does not provide a recommendation for the next steps in the patient’s care. The R step in SBAR stands for Recommendation, which involves suggesting what should be done to address the situation. Stating that there are no provider’s prescriptions available does not fulfill this requirement.
Choice B rationale
This statement is more appropriate for the Assessment step, where the nurse describes the patient’s current condition. The R step should focus on what actions need to be taken next, not just the patient’s current state.
Choice C rationale
This statement is correct because it provides a clear recommendation for the next steps in the patient’s care. The R step in SBAR is meant to suggest what should be done to address the situation, and reviewing the client’s orders is a specific action that can be taken.
Choice D rationale
This statement is more appropriate for the Situation or Background steps, where the nurse describes what has happened to the patient. The R step should focus on what actions need to be taken next, not just the patient’s history.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale
A patient who experiences postural hypotension is at a higher risk for falls. Postural hypotension, or a sudden drop in blood pressure upon standing, can cause dizziness and increase the likelihood of falling. This condition is common in older adults and those with certain medical conditions.
Choice B rationale
A patient who is experiencing nausea from chemotherapy is not necessarily at a higher risk for falls. While nausea can cause discomfort and weakness, it does not directly contribute to an increased risk of falling. Other factors, such as medication side effects or balance issues, are more significant in fall risk assessment.
Choice C rationale

A patient who has already fallen twice is at a higher risk for future falls. A history of falls is a strong predictor of subsequent falls, as it may indicate underlying issues such as balance problems, muscle weakness, or environmental hazards.
Choice D rationale
A patient who is older than 50 years old is not automatically at a higher risk for falls. While age is a factor, the risk significantly increases for individuals over 65 years old. Other factors, such as medical conditions and medication use, play a more critical role in fall risk assessment.
Choice E rationale
A patient who is transferred to long-term care is at a higher risk for falls. The transition to a new environment can be disorienting, and patients may be unfamiliar with their surroundings. Additionally, long-term care patients often have multiple health issues that contribute to an increased fall risk.

A. Teaching a client about the use of the incentive spirometer. B. Administering routine medications. C. Assisting with activities of daily living. D. Monitoring vital signs. E. Providing wound care.

Correct Answer is ["B","C","D"]

Explanation

The correct answers are Choices B, C, and D.

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A nurse is planning to use the SBAR communication tool when giving an oncoming shift report. Which of the following statements should the nurse include in the R step?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

An RN has a critical client that needs constant monitoring. However, the RN also has other clients in need of care. Which tasks below could the RN delegate to the LPN? Select three.

Correct Answer is ["B","C","D"]

Explanation

A nurse instructs the UAP using the Self-Care Model. Which action demonstrates use of the Self-Care Model when providing care?

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In what patient situations would a partial ongoing assessment be best performed?

A nurse is teaching a client who wishes to stop smoking. Which of the following teaching methods uses the cognitive domain of learning?

A nurse is filing a safety event report for a client who fell when getting out of bed. What action is performed appropriately?

Which of the following actions can help reduce falls in older adults?

A home health nurse is assessing an older adult client who reports falling a couple of times over the past month. Which of the following findings should the nurse suspect is contributing to the client’s falls?

A physician verbally orders a medication. What should the nurse do first?