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.
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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Related Questions
Correct Answer is B
Explanation
A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.
Correct Answer is A
Explanation
A. Not providing an interpreter for a client who speaks a different language may violate the client's right to understand their care, leading to potential legal issues regarding informed consent and patient safety.
B. A provider speaking to a client alone about suspected partner violence is appropriate as it ensures the client's privacy and safety during a sensitive discussion.
C. Prescribing a kosher meal tray for a client who practices the Orthodox Jewish faith is respectful and meets the dietary needs of the client, which is not a legal issue.
D. A client requesting that a nurse provide information to their partner is not inherently a legal issue, but the nurse must ensure that the client has consented to share their information to protect confidentiality.
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