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A nurse is providing client report using the Situation, Background, Assessment, Recommendation (SBAR) format. Using SBAR, in which order should the nurse provide the information in the report? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The client's temperature is 39.5° C (103.1° F).

Contact the client's provider for a prescription for a sputum culture.

The client reports increasing shortness of breath.

The client has COPD.

Answer and Explanation

The Correct Answer is D,C,A,B

Rationale

Situation: The client has COPD and is experiencing an acute exacerbation.
Background: The client has a history of COPD and has been experiencing increasing shortness of breath.
Assessment: The client's temperature is 39.5°C (103.1°F) and is experiencing shortness of breath.
Recommendation: Contact the client's provider for a prescription for a sputum culture.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Logging the previous user out of the system immediately ensures the client's health information is no longer visible, protecting the client's privacy according to HIPAA guidelines.
B. Offering to conduct an in-service on client confidentiality is a proactive measure but does not address the immediate privacy issue.
C. Reporting the incident to the charge nurse is appropriate but does not prevent unauthorized viewing of the client's information immediately.
D. Completing an incident report is necessary to document the breach, but it should occur after protecting the client’s privacy by logging out.

A. Abdominal CT scan with contrast. B. Esophagogastroduodenoscopy. C. Insertion of an NG tube to low intermittent suction. D. Administration of 1 unit of fresh frozen plasma.

Correct Answer is C

Explanation

A. An abdominal CT scan with contrast typically requires specific informed consent due to the use of contrast material and potential risks associated with it.
B. An esophagogastroduodenoscopy is an invasive procedure that necessitates special informed consent due to its risks and potential complications.
C. The insertion of an NG tube to low intermittent suction is considered a routine procedure that is generally included under the client's general consent for treatment.
D. The administration of fresh frozen plasma involves specific risks and usually requires informed consent because of the implications of blood product administration.

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Naxlex Comprehensive Predictor Exams

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse reviewing prescriptions for a client who has a gastrointestinal bleed is determining the need for special informed consent. Which of the following prescriptions should the nurse identify as covered under the client's general consent for treatment?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

A nurse is collecting data from a client who is 1 day postoperative following a total hip arthroplasty. Which of the following findings is the priority for the nurse to report to the provider?

A nurse is assisting with the planning of an in-service for a group of newly licensed nurses about transcribing prescriptions from a provider. Which of the following examples should the nurse include as an approved abbreviation?

A nurse is asked by the unit manager to provide input for the performance appraisal of an assistive personnel (AP). Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.

A nurse is caring for a client who has a terminal illness and states that they wish to discontinue their enteral feedings. The nurse responds by saying, "You have a right to refuse treatment." This response by the nurse demonstrates which of the following ethical principles?