A nurse is planning to use the SBAR communication tool when giving on coming shift report. Which of the following statements should the nurse include in the R step?
"There are no provider's prescriptions available."
"The client should be seen by a neurologist."
"The client is disoriented. Pupils are slow to respond to light."
"The client was found unconscious on the floor in her home."
The Correct Answer is B
A. "There are no provider's prescriptions available." This statement is about the current situation or background, not a recommendation.
B. "The client should be seen by a neurologist." The Recommendation (R) step involves suggesting actions or solutions, such as recommending that the client be seen by a neurologist.
C. "The client is disoriented. Pupils are slow to respond to light." This statement belongs in the Assessment (A) step as it describes the nurse’s clinical findings.
D. "The client was found unconscious on the floor in her home." This statement provides background information (B) about the client’s situation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client will be able to lift more than 50 pounds after abdominal surgery on post-op day 1. This goal is not realistic or safe for a client post-abdominal surgery on day 1.
B. The client will be able to describe ALL the signs and symptoms of COPD. This goal is not realistic or specific enough to be measurable and achievable.
C. The client will be able to tolerate 50% of his meal at lunch. This goal is Specific, Measurable, Achievable, Relevant, and Time-bound (SMART).
D. The client states his wound is improving. This goal is not measurable or specific.
Correct Answer is B
Explanation
A. Speak loudly and use simple words: Speaking loudly may be perceived as shouting and can increase agitation. Using simple words is appropriate, but volume should be normal and calm.
B. Address the client by name and reorient client: Addressing the client by name and reorienting him is effective because it respects his dignity and helps him understand his current situation, reducing confusion and agitation. This approach is clear, respectful, and supportive.
C. Challenge the client to refocus his attention when he becomes agitated: Challenging the client can be confrontational and may escalate agitation. It is better to use a calm, reassuring approach.
D. Ask the client a series of questions without allowing time for the client to answer: This can overwhelm and frustrate the client, leading to increased agitation.
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