A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?
Client's present condition.
Suggestions for the provider regarding client care.
Physical findings.
Previous treatments.
The Correct Answer is A
Choice A rationale:
In the "background" portion of the SBAR communication tool, the nurse should include the client's present condition. This information provides the provider with context and a clear understanding of the client's current status. It helps the provider to have a baseline understanding before moving on to the assessment and recommendation stages of the communication. Including the client's present condition allows the provider to quickly grasp the urgency and severity of the situation, enabling them to make informed decisions regarding the client's care.
Choice B rationale:
Suggestions for the provider regarding client care are typically included in the "assessment" or "recommendation" portions of the SBAR communication tool, rather than the "background" portion. The "background" portion is focused on providing information about the current situation and the client's present condition, setting the stage for the rest of the communication.
Choice C rationale:
Physical findings are part of the assessment and observation of the client's current condition. While important, these findings are better suited for the "assessment" portion of the SBAR communication. The nurse should summarize the physical findings in the "assessment" section after providing the context in the "background" section.
Choice D rationale:
Previous treatments are also relevant information, but they belong in the "assessment" or "background" portions of the SBAR communication tool. The nurse should provide the provider with information about the client's current condition before discussing previous treatments, as the provider needs to know the current situation before considering the relevance of past interventions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.
Choice B rationale:
Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.
Choice C rationale:
Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.
Choice D rationale:
Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to ambulate is not appropriate when the client has a high fever of 40°C (104°F). Ambulation requires physical exertion and can potentially worsen the client's condition, especially when they are already experiencing discomfort due to the fever.
Choice B rationale:
Giving the client a cold sponge bath might seem like a logical approach to reduce fever; however, it is not the most effective and safest method. Cold water can cause vasoconstriction and shivering, potentially increasing the body's metabolic demands and raising the temperature further. Additionally, sudden temperature changes can be uncomfortable and may not provide sustained fever reduction.
Choice C rationale:
Administering antipyretics as prescribed is the correct choice. Antipyretic medications, such as acetaminophen or ibuprofen, work to lower fever by acting on the hypothalamus, the body's temperature-regulating center. By reducing fever, the body's metabolic rate and oxygen consumption are decreased, which can help prevent complications associated with high fever, such as dehydration and discomfort.
Choice D rationale:
Providing a cooling fan can offer some comfort, but it might not be sufficient to effectively lower the client's high fever. Fans primarily work by promoting evaporative cooling, which may not be efficient when the body temperature is significantly elevated. Additionally, relying solely on a cooling fan might delay the necessary intervention of administering antipyretic medication.
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