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 C
Explanation
Choice A reason: Irrigating and performing a dressing change for a client who has a pressure injury wound is not a task that the nurse should delegate to an AP. This task requires the nurse's clinical judgment, skill, and knowledge to assess the wound, select the appropriate dressing, and prevent infection. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice B reason: Administering oral PRN pain medication to a client who has arthritis is not a task that the nurse should delegate to an AP. This task involves the nurse's responsibility to evaluate the client's pain level, determine the need and the dosage of the medication, and monitor the client's response and side effects. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Choice C reason: Obtaining a daily weight on a client who has heart failure is a task that the nurse can delegate to an AP. This task is a routine and standardized procedure that does not require the nurse's clinical judgment, skill, or knowledge. This task is also within the AP's scope of practice, if the nurse provides clear directions and supervision.
Choice D reason: Reinforcing teaching the use of an incentive spirometer to a postoperative client is not a task that the nurse should delegate to an AP. This task involves the nurse's role to educate the client about the purpose, benefits, and technique of using the incentive spirometer, and to evaluate the client's understanding and compliance. This task is also within the nurse's scope of practice, but not the AP's scope of practice.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because an interprofessional team does not necessarily decrease the number of visits to client by staff. In fact, an interprofessional team may increase the frequency and quality of communication and interaction between the client and the staff, as each member of the team contributes their expertise and perspective to the client's care. This can enhance the client's satisfaction, engagement, and education.
Choice B reason: This statement is correct because an interprofessional team can improve the efficiency in client care services. An interprofessional team can coordinate and integrate the care delivery across different disciplines, settings, and levels of care, reducing the duplication, fragmentation, or gaps in the services. This can also lower the costs and risks of care, and improve the outcomes and quality of care.
Choice C reason: This statement is incorrect because an interprofessional team does not increase the length of stay for client. On the contrary, an interprofessional team can reduce the length of stay for client by providing timely, appropriate, and effective care that meets the client's needs and goals. This can also prevent the readmission or complication of the client, and facilitate the transition and discharge of the client.
Choice D reason: This statement is incorrect because an interprofessional team does not decrease the number of referrals needed for client. Rather, an interprofessional team can enhance the referral process by ensuring that the client receives the right service from the right provider at the right time. An interprofessional team can also collaborate and communicate with the referral sources, and follow up on the client's progress and response to the service.
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