A nurse is using SBAR. Which information will the nurse report for the “B”?
The nurse requests that the primary health care provider examines the patient.
The patient has a fractured right leg with a cast that was applied 2 days ago.
The patient’s toes are cool and pale and the patient reports that the foot feels numb.
The patient is reporting severe pain 1 hour after pain medication was given.
The Correct Answer is B
Choice A reason: This is an incorrect choice because the nurse requests that the primary health care provider examines the patient is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The nurse's request is part of the “R”, which stands for recommendation, which is the action that the nurse suggests or requests.
Choice B reason: This is the correct choice because the patient has a fractured right leg with a cast that was applied 2 days ago is the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's fracture and cast are part of the patient's background that the nurse should share with the primary health care provider.
Choice C reason: This is an incorrect choice because the patient’s toes are cool and pale and the patient reports that the foot feels numb is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's toes and foot are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.
Choice D reason: This is an incorrect choice because the patient is reporting severe pain 1 hour after pain medication was given is not the information that the nurse reports for the “B”. The “B” stands for background, which is the relevant information about the patient's history, diagnosis, and treatment. The patient's pain and medication are part of the patient's current condition that the nurse should report for the “S”, which stands for situation, which is the reason for the communication and the patient's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect. The patient frequently using an alcohol-based sanitizer for hand hygiene does not pose a risk for poisoning. Alcohol-based sanitizers are safe and effective for reducing the transmission of germs.
Choice B reason: This is correct. The patient taking acetaminophen 1000 mg every 4 hours around the clock poses a risk for poisoning. Acetaminophen is a common over-the-counter pain reliever that can cause liver damage or failure if taken in excess or for a prolonged period of time. The maximum daily dose of acetaminophen for adults is 4000 mg.
Choice C reason: This is incorrect. The patient taking alprazolam 0.25 mg every 3 hours does not pose a risk for poisoning. Alprazolam is a prescription medication that belongs to the benzodiazepine class of drugs. It is used to treat anxiety and panic disorders. It can cause side effects such as drowsiness, dizziness, or dependence, but not poisoning.
Choice D reason: This is incorrect. The patient rinsing with a fluoride mouthwash after brushing the teeth does not pose a risk for poisoning. Fluoride is a mineral that helps prevent tooth decay and strengthen the enamel. It is added to many dental products and public water supplies. It can cause mild stomach upset if swallowed in large amounts, but not poisoning.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because health-seeking behaviors related to expressed desire for better sleep is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Health-seeking behaviors are actions that a person takes to improve their health and well-being. However, this is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because impaired bed mobility related to presence of CPAP mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Impaired bed mobility is the limitation of the patient's ability to move in bed. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice C reason: This is an incorrect choice because risk for impaired skin integrity related to tight-fitting mask on face is not the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for impaired skin integrity is the potential for the patient's skin to be damaged or broken. However, this is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
Choice D reason: This is the correct choice because risk for powerlessness related to inability to breathe regularly during sleep is the highest priority nursing diagnosis for a patient who is starting CPAP therapy for sleep apnea. Risk for powerlessness is the potential for the patient to feel a loss of control or self-efficacy. This is the most urgent and life-threatening problem for the patient, as it can result in psychological distress, anxiety, depression, or hopelessness.
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