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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
A. Client 1: The client with Pertussis should have individuals wear surgical masks when within 3 feet of the client, not 1 foot. Pertussis is highly contagious, and proper precautions are necessary to prevent transmission
B. Client 2: The client with Clostridium difficile is placed in a private room, and nurses wear gowns and gloves during direct care. These are appropriate contact precautions for preventing the spread of C. difficile.
C. Client 3: The client with Herpes simplex is managed with nurses wearing gowns and gloves during direct care, which is appropriate for preventing the spread of the virus through direct contact.
D. Client 4: The client with Mycobacterium tuberculosis should be placed in a negative airflow room, not a positive airflow room. Negative airflow rooms help contain airborne pathogens and prevent them from spreading to other areas.
E. Client 5: The client with Streptococcal pharyngitis is placed in a private room, and the client wears a surgical mask when transported outside their room. These are appropriate droplet precautions to prevent the spread of infection.
Correct Answer is C
Explanation
A. While the pharmacy should be notified of errors to improve systems, the immediate priority is the client's safety and the provider's notification. Reporting to the pharmacy manager is a secondary administrative step, not the first or most critical action.
B. Incident reports should not be placed in the client's medical record, as they are separate documents meant for internal review and quality improvement.
C. When a medication error occurs, the nurse’s primary responsibility is to ensure the safety of the client and maintain an accurate medical record of what actually happened to the patient.
D. Contacting the nurse from the previous shift may be necessary for understanding the situation, but the priority is to report the incident properly to ensure patient safety.
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