A nurse is using the I-SBAR tool to provide report on a client to an oncoming nurse. In which of the following components of I-SBAR should the nurse include the client's lung sounds?

Situation

Recommendation

Introduction

Assessment

Answer and Explanation

The Correct Answer is D

A. Situation This component includes the immediate issue or reason for the report.
B. Recommendation This includes what the nurse suggests or recommends should happen next.
C. Introduction This includes the nurse's name, role, and patient details.
D. Assessment This includes the nurse's findings, including lung sounds, vital signs, and other assessment data.

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Correct Answer is A

Explanation

A. "If I continue to breathe in carbon monoxide, I could become unconscious." This is correct. Continued exposure to carbon monoxide can lead to unconsciousness and even death.
B. "If there is carbon monoxide in my house. I'll be able to smell it." This is incorrect. Carbon monoxide is a colorless and odorless gas, making it impossible to detect by smell.
C. "I have a gas furnace, so I don't have to worry about carbon monoxide." This is incorrect. Gas furnaces can produce carbon monoxide, especially if they are not properly ventilated or maintained.
D. "I will change the battery in my carbon dioxide detector every 2 years." This is incorrect. The batteries in carbon monoxide detectors should be changed more frequently, typically every 6-12 months, to ensure they function properly.

A. Install a bed exit sensor pad at the foot of the client's bed. B. Encourage the client to ambulate in compression stockings. C. Raise all four side rails for the client at bedtime. D. Place a raised toilet seat in the client's bathroom.

Correct Answer is D

Explanation

A. Install a bed exit sensor pad at the foot of the client's bed. While a bed exit sensor pad can be useful, it is typically placed on the mattress near the client's hips or lower back, not at the foot of the bed. This placement ensures it detects movement when the client tries to get up, thereby alerting staff to provide assistance.
B. Encourage the client to ambulate in compression stockings. Compression stockings can help with circulation but do not directly address fall prevention. Additionally, they can be slippery on some surfaces, potentially increasing the risk of falls if proper footwear is not used.
C. Raise all four side rails for the client at bedtime. Raising all four side rails is considered a form of restraint and can increase the risk of injury if the client attempts to climb over them. It can also limit the client’s ability to get out of bed independently and safely.
D. Place a raised toilet seat in the client's bathroom. This intervention is appropriate for fall prevention. A raised toilet seat can help clients with mobility issues by making it easier to sit down and stand up, thereby reducing the risk of falls in the bathroom, which is a common site for falls.

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A nurse is using the I-SBAR tool to provide report on a client to an oncoming nurse. In which of the following components of I-SBAR should the nurse include the client's lung sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients in a community center about carbon monoxide poisoning at home. Which of the following statements by a client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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