A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (ISBARR) on a client. Which of the following information should be included in the situation component?
Provider notified of client’s back pain
Request prescription for opioid medication for pain relief
Client is grimacing due to pain
Client admitted with ruptured disc at L5
The Correct Answer is C
Choice A reason: This statement belongs to the recommendation component, as it describes an action that the nurse has taken or suggests to take regarding the client's care.
Choice B reason: This statement also belongs to the recommendation component, as it expresses a need or a request for the client's treatment.
Choice C reason: This statement belongs to the situation component, as it summarizes the current problem or issue that the client is facing.
Choice D reason: This statement belongs to the background component, as it provides relevant information about the client's medical history or diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because right documentation is not one of the five rights of delegation. Right documentation is a responsibility of the nurse and the AP, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice B reason: This statement is correct because right communication is one of the five rights of delegation. Right communication means that the nurse provides clear, concise, and specific instructions to the AP, and that the AP acknowledges and understands the instructions. Right communication also involves feedback, reporting, and documentation between the nurse and the AP.
Choice C reason: This statement is incorrect because right time is not one of the five rights of delegation. Right time is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice D reason: This statement is incorrect because right room is not one of the five rights of delegation. Right room is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: This is correct. Caring is one of the interlocking principles of shared governance. Caring refers to the nurse's commitment to the well-being of patients, families, colleagues, and the profession. Caring also involves the nurse's self-care and professional development. Caring is the foundation of nursing practice and the core value of shared governance.
Choice B reason: This is incorrect. Navigation is not one of the interlocking principles of shared governance, but a skill that nurses need to practice shared governance. Navigation refers to the nurse's ability to navigate the complex and dynamic health care environment, and to adapt to changes and challenges. Navigation also involves the nurse's use of evidence, technology, and innovation to improve outcomes and quality of care².
Choice C reason: This is incorrect. Finance is not one of the interlocking principles of shared governance, but a factor that influences shared governance. Finance refers to the financial resources and constraints that affect the health care system and the nursing profession. Finance also involves the nurse's understanding of the economic impact of their practice and decisions, and their participation in budgeting and resource allocation.
Choice D reason: This is correct. Leading is one of the interlocking principles of shared governance. Leading refers to the nurse's role as a leader and a follower in the health care team and the organization. Leading also involves the nurse's empowerment, autonomy, accountability, and collaboration. Leading is the key to achieving shared governance and transforming nursing practice.
Choice E reason: This is correct. Knowing is one of the interlocking principles of shared governance. Knowing refers to the nurse's knowledge and expertise in their specialty and practice area. Knowing also involves the nurse's lifelong learning, inquiry, and scholarship. Knowing is the basis of nursing excellence and the driver of shared governance.
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