A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

"The client is 2 hours postoperative following a cholecystectomy."

"The client rates her pain at a 3 on a 0 to 10 pain rating scale."

"The client has type 2 diabetes mellitus."

"The client should wear compression stockings."

Answer and Explanation

The Correct Answer is B

A.   "The client is 2 hours postoperative following a cholecystectomy." This belongs in the "B" (Background) section since it provides historical or procedural information.
B.   "The client rates her pain at a 3 on a 0 to 10 pain rating scale." This is part of the "A" (Assessment) portion as it involves the nurse's evaluation of the client's current condition.
C.   "The client has type 2 diabetes mellitus." This is background information relevant to the client's medical history and should be included in the "B" section.
D.   "The client should wear compression stockings." This is part of the "R" (Recommendation) section as it involves future care instructions.

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Correct Answer is A

Explanation

A. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

A. Bowel pattern B. Oxygen saturation C. Respiratory assessment. D. Temperature E. Neurological status F. X-ray results G. Heart rate

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

Explanation

B.Oxygen saturation (92% on room air): A drop in oxygen saturation from 96% to 92% indicates impaired gas exchange, which may require oxygen therapy or further evaluation for respiratory compromise.
C. Respiratory assessment (crackles, chest tightness, productive cough with blood): Crackles and productive cough with hemoptysis are concerning for possible tuberculosis (TB) or another serious respiratory infection. Immediate notification ensures timely isolation and further diagnostic testing.
D. Temperature (38.8°C/101.8°F): The elevated temperature indicates a possible infection or worsening inflammatory process, especially concerning given the night sweats and recent international travel history.
E. Neurological status (lethargy): The progression from an alert state to lethargy suggests potential worsening of the client’s condition, possibly due to hypoxia, infection, or sepsis. Early identification is critical for preventing deterioration.
F. X-ray results (calcification in upper lobes): Calcifications in the upper lung lobes are characteristic of previous or latent TB infection. This, combined with the client’s current symptoms, requires prompt reporting to initiate appropriate infection control measures.

Findings Not Reported:
A.Bowel pattern (normoactive, last BM this morning): The bowel pattern is normal and not immediately relevant to the acute respiratory concerns.
G. Heart rate (114/min): Though elevated, the heart rate is likely a secondary response to the fever and respiratory compromise. While important to monitor, it does not warrant immediate provider notification independently.

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A nurse is preparing to provide a change-of-shift report. Using the SBAR communication technique, which of the following client information should the nurse include in the "A" portion of the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who speaks a different language than the nurse. Which of the following interventions should the nurse include to facilitate communication with the client?

Correct Answer is A

Explanation

A nurse is assisting in the care of a client. Exhibits The nurse is assisting in the care of the client. Which of the following findings should the nurse report to the provider? Select the 5 findings the nurse should report.

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

Explanation

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