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 D
Explanation
Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.
Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.
Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.
Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.
Correct Answer is A
Explanation
Choice A rationale:
Providing oral replacement solution is the nurse's priority in this situation. Diarrhea can lead to dehydration and electrolyte imbalances due to fluid loss. Oral rehydration solutions contain electrolytes and fluids that can help restore the body's hydration balance. Ensuring the client's adequate fluid intake takes precedence in preventing complications associated with diarrhea.
Choice B rationale:
Obtaining a prescription for antidiarrheal medication is important, but it is not the priority action. The client's dehydration and electrolyte imbalance should be addressed first through oral rehydration before focusing on symptom management.
Choice C rationale:
Offering the client a sitz bath is not the priority action for someone experiencing diarrhea. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or perineal discomfort. However, in the case of diarrhea, the primary concern is managing fluid and electrolyte balance.
Choice D rationale:
Collecting a specimen of the client's stool is important for diagnostic purposes, but it is not the immediate priority. The client's hydration status and electrolyte balance should be addressed promptly to prevent complications. Stool collection can be considered once the client's hydration has been stabilized.
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