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 D

Explanation

A. Perform CPR for a client who is not breathing: CPR is within the scope of trained assistive personnel, but a nurse or advanced provider typically manages it in an emergency scenario.
B. Complete distal capillary refill checks for a client who has an open leg wound: Capillary refill checks require clinical assessment skills, which are outside the AP's scope of practice.
C. Determine which clients need priority medical treatment: Triage and prioritization require clinical judgment, which is the nurse's responsibility.
D. Answer questions from area residents who have health concerns: APs can answer non-clinical questions and provide basic information to area residents.

A. "Have you tried holding your infant skin-to-skin?" B. "Have you considered joining a parents' support group?" C. "What is your infant's level of activity?" D. "Is your infant able to latch on during breastfeeding?"

Correct Answer is D

Explanation

A. "Have you tried holding your infant skin-to-skin?": Important for bonding and soothing but not the priority for postoperative care.
B. "Have you considered joining a parents' support group?": Beneficial for emotional support but not immediately essential for the infant's recovery.
C. "What is your infant's level of activity?": Relevant for assessing overall recovery but not the most critical issue.
D. "Is your infant able to latch on during breastfeeding?" Feeding is the priority concern after cleft palate repair to ensure adequate nutrition and assess for complications.

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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 caring for residents at a long-term care facility following a tornado. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A home health nurse is visiting the home of a 9-month-old infant who is 2 weeks postoperative following a cleft palate repair. Which of the following questions is the priority for the nurse to ask?

Correct Answer is D

Explanation

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