A nurse is using the introduction, situation, background, assessment, recommendation, and readback (I-SBAR-R) communication tool when contacting a provider about a client who has COPD.
Which of the following statements by the nurse should be included in the assessment component?
"The client has a respiratory rate of 38/min.”.
"The client has a history of COPD.”.
"Should I increase the client's supplemental oxygen?"
"I will obtain a sputum culture.”.
The Correct Answer is A
Choice A rationale
In the I-SBAR-R communication tool, the assessment component focuses on the nurse's current clinical findings and observations regarding the patient's status. Stating that the respiratory rate is 38 per minute provides a specific, objective clinical measurement that indicates the patient is in acute respiratory distress. The normal adult respiratory rate is 12 to 20 breaths per minute. Reporting this data allows the provider to understand the severity of the situation based on the nurse's immediate physical assessment.
Choice B rationale
Mentioning the history of COPD belongs in the background section of the I-SBAR-R tool. The background component provides context for the current situation by detailing the patient's medical history, previous treatments, or allergies. While this information is vital for the provider to understand the patient's baseline and underlying pathology, it is not part of the active assessment of the current acute problem. The assessment section should instead prioritize the current vital signs and physical manifestations.
Choice C rationale
Asking if the supplemental oxygen should be increased is part of the recommendation component of the I-SBAR-R tool. In the recommendation phase, the nurse suggests a specific intervention or asks for a particular order to address the problem identified in the assessment. While this is a critical part of the communication process, it occurs after the nurse has presented the assessment data. The recommendation is the final step where the nurse advocates for the patient's needs.
Choice D rationale
Stating the intention to obtain a sputum culture is also part of the recommendation or plan of action. It reflects a diagnostic step that the nurse proposes or anticipates based on the assessment findings. The assessment component itself is strictly for reporting what the nurse has observed or measured, such as breath sounds, oxygen saturation, or respiratory effort. Proposing future actions belongs at the end of the report to facilitate clear orders from the healthcare provider.
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Correct Answer is D
Explanation
Choice A rationale
This statement is incorrect because the National Council of State Boards of Nursing and the American Nurses Association recognize 5 rights of delegation, not 4. These rights include the right task, right circumstance, right person, right direction or communication, and right supervision or evaluation. Omitting any of these rights increases the risk of medical errors and compromises patient safety, as each component is essential for the legal and clinical validity of the delegation process.
Choice B rationale
While a nurse manager has overall responsibility for the unit's functioning, the primary responsibility for delegating specific nursing tasks during a shift lies with the individual licensed nurse. The registered nurse must assess the client's needs and the competency of the assistive personnel before delegating. Delegating is a dynamic, clinical decision-making process that occurs at the bedside throughout the shift rather than a static administrative duty performed solely by management.
Choice C rationale
This statement is dangerous and professionally inaccurate. A delegatee has a professional obligation to ask questions and seek clarification if they do not understand a task or feel incompetent to perform it safely. Clear communication is one of the five rights of delegation. If an assistive person performs a task without proper understanding, it can lead to patient injury. The delegating nurse must ensure the delegatee understands the expectations and reporting parameters.
Choice D rationale
This is the correct statement because the delegating nurse retains accountability for the outcome of the delegated task. While the delegatee is responsible for the performance of the activity, the licensed nurse is responsible for supervising, monitoring, and evaluating the results. The nurse must ensure the task was completed correctly and documented appropriately. This oversight ensures that the patient receives safe and effective care despite the task being performed by another individual.
Correct Answer is D
Explanation
Choice A rationale
This explanation describes the mechanism of extended-release or sustained-release medications rather than enteric-coated tablets. Enteric coating is designed to resist dissolution in the acidic environment of the stomach and instead dissolve in the more alkaline environment of the small intestine. While crushing some medications causes a rapid release of the entire dose, the primary scientific concern with enteric-coated aspirin is the loss of gastric protection rather than the specific rate of systemic absorption.
Choice B rationale
Crushing an enteric-coated tablet does not destroy the active pharmacological ingredients of the aspirin itself; rather, it alters the physical delivery system. The aspirin remains chemically active but loses its protective outer layer. Claiming the ingredients are destroyed is scientifically inaccurate. The primary issue is that the medication will now exert its effects in the wrong part of the gastrointestinal tract, potentially leading to adverse local effects on the gastric mucosa that the coating was intended to prevent.
Choice C rationale
Suggesting that the nurse can crush enteric-coated medication and mix it with food is incorrect and potentially harmful. Crushing these tablets bypasses the intended safety mechanism, exposing the stomach lining to the irritating effects of aspirin. This can lead to gastritis or peptic ulcers. The nurse should never encourage altering a medication's form if it is specifically formulated with an enteric coat, as this violates standard pharmacological principles and safe medication administration practices for the client.
Choice D rationale
Enteric coating is specifically applied to aspirin to protect the gastric mucosa from direct irritation and to prevent the drug from being deactivated by stomach acid. If the coating is crushed, the aspirin is released prematurely in the stomach, significantly increasing the risk of gastric irritation, dyspepsia, and indigestion. Explaining this risk helps the client understand that the coating is a safety feature intended to prevent gastrointestinal discomfort and potential injury like ulcers or bleeding.
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