A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

The client's code status

The client's name

A prescribed consultation

The client's vital signs

Answer and Explanation

The Correct Answer is C

A.   The client’s code status (e.g., full code, do not resuscitate) is crucial information for any healthcare provider, especially when transferring care. However, this detail is typically included in the Situation or Assessment sections rather than the Background. It is important to communicate the code status clearly, but it is not part of the historical or contextual information provided in the Background section.
B.   While the client's name is important for identification, it is usually not detailed in the Background section. Instead, it is generally included at the beginning of the report or in the Situation section where initial identification and immediate concerns are presented.
C.   Information about a prescribed consultation (e.g., a referral to a specialist) falls under the Background section of the SBAR. This part of the report should include pertinent historical details and context, such as any previous consultations or significant events that have impacted the client’s current condition.
D.   Vital signs are crucial for assessing the current status of the client but are usually included in the Assessment section of the SBAR. This section provides a summary of the client’s current condition, including vital signs, lab results, and other relevant clinical data.

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Correct Answer is ["A","B","C"]

Explanation

A. Documenting a client's refusal to take prescribed medication is an important aspect of client advocacy. It respects the client’s right to refuse treatment and ensures that their decision is clearly recorded in their medical record.
B. Obtaining an interpreter for a client who speaks a different language is a key example of client advocacy. It ensures that the client can understand and participate in their own care, which is essential for informed consent and effective communication.
C. Providing written information about palliative care supports client advocacy by ensuring that the client is informed about their care options. This helps the client make informed decisions about their care, which is a crucial aspect of advocacy.
D. Implementing a plan of care based on nursing goals is part of routine nursing practice but does not directly reflect client advocacy unless those goals are specifically aligned with the client's preferences and needs.
E. Initiating IV access on a client who has dementia while they are sleeping does not exemplify client advocacy. Informed consent and respect for the client’s comfort and awareness are crucial, especially for clients with cognitive impairments.

A. Uses sterile forceps to pack sterile gauze into the wound B. Uses a sterile-gloved hand to adjust the back of the sterile gown C. Sets up the sterile field 30 min prior to performing the dressing change D. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape

Correct Answer is A

Explanation

A. Using sterile forceps to pack the wound helps maintain the sterility of the field by preventing contact with non-sterile surfaces. This action minimizes the risk of contaminating the wound with microorganisms, which can lead to infection.
B. This action does not maintain sterile technique. Once the sterile gown is donned, the back should not be touched, as this can contaminate the sterile field.
C. This is not recommended. Sterile fields should be set up as close to the time of the procedure as possible to minimize the risk of contamination.
D. This is not recommended. Sterile gauze should be placed within 1 inch of the edge of a sterile drape to prevent contamination from the non-sterile area.

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A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?

Correct Answer is A

Explanation

A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?

A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

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