A nurse is preparing to provide report on a client using the Situation-Background- Assessment-Recommendation (SBAR) Communication tool.
Identify the order in which the nurse should give report.
Provide a brief description of the client’s diagnosis.
Discuss suggestions for continuing the client’s care.
State the client’s most recent vital signs.
Review the client’s pertinent medical history.
The Correct Answer is B
The nurse should give report using the SBAR Communication tool in the following order: Situation, Background, Assessment, Recommendation. This tool provides a framework for communication between members of the health care team about a patient’s condition. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team.
Choice A is wrong because it is part of the Background section of the SBAR tool, which comes after the Situation section.
Choice C is wrong because it is part of the Assessment section of the SBAR tool, which comes after the Background section.
Choice D is wrong because it is also part of the Background section of the SBAR tool, which comes after the Situation section.
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Related Questions
Correct Answer is C
Explanation
Clean the cannula prongs daily.
This is because the nasal cannula can become contaminated with bacteria and mucus, which can cause infection and irritation of the nasal mucosa. Cleaning the cannula prongs daily with soap and water can prevent these complications.
Choice A is wrong because humidifiers can help moisten the dry oxygen and prevent nasal dryness and bleeding. Humidifiers should be used for oxygen flow rates higher than 4 L/min.
Choice B is wrong because the cannula prongs should be positioned curving downward in the nose, not upward. This allows for better alignment with the natural direction of airflow and reduces the risk of dislodgement.
Choice D is wrong because keeping the oxygen tubing off the floor is not a specific action for nasal cannula use. It is a general safety measure to prevent tripping and contamination of the tubing.
Correct Answer is A
Explanation
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
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