A nurse needs to communicate an urgent situation involving a client who has deteriorating vital signs. Using the ISBARR tool, what should the nurse prioritize immediately after introducing themselves and stating their role?
Request specific recommendations from the provider.
Describe the current client condition and critical changes requiring attention.
Read back the orders given by the provider for clarification.
Provide detailed background information including medical history.
The Correct Answer is B
A. Request specific recommendations from the provider: This step occurs later during the Recommendation portion of ISBARR. At the beginning of the communication, the nurse must first clearly state why the call is urgent before asking for orders or guidance.
B. Describe the current client condition and critical changes requiring attention: After identification, the Situation is prioritized to immediately communicate what is happening now. This ensures the provider quickly understands the urgency related to deteriorating vital signs.
C. Read back the orders given by the provider for clarification: Read-back occurs at the end of the communication to confirm accuracy of orders. It is not appropriate until recommendations have been made and instructions received.
D. Provide detailed background information including medical history: Background information follows the situation and should be concise. Providing extensive history too early can delay recognition of a life-threatening change in the client’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide nutritional supplements instead of accommodating cultural preferences: While supplements may meet nutritional needs, ignoring cultural preferences can reduce patient satisfaction and adherence to dietary recommendations, potentially impacting overall care.
B. Advise the patient to follow the hospital's standard meal plan: Forcing standard meals without considering cultural restrictions may cause distress, reduce intake, and compromise nutritional status. Respecting cultural needs supports holistic care.
C. Request the patient to bring meals from home to avoid complications: While bringing food from home may help, it may not meet the hospital’s safety standards or provide balanced nutrition. This is not a sustainable or controlled solution.
D. Collaborate with the dietary team to ensure meals align with the patient's cultural preferences: Partnering with the dietary team allows the patient’s cultural practices to be respected while maintaining safe, balanced nutrition. This promotes adherence, satisfaction, and holistic patient-centered care.
Correct Answer is C
Explanation
A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. There may be a shallow open ulcer, blister, or abrasion, but subcutaneous fat is not visible. The described wound is deeper, so it does not fit Stage II criteria.
B. Stage I: Stage I pressure injuries are characterized by intact skin with non-blanchable erythema. There is no tissue loss or ulceration, making this stage inconsistent with the wound described.
C. Stage III: Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous fat. The wound extends below the dermis into the subcutaneous tissue, creating a deep depression. This description matches the characteristics of a Stage III pressure injury.
D. Stage IV: Stage IV pressure injuries involve full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Since the description mentions subcutaneous fat but no bone, tendon, or muscle exposure, Stage IV is not appropriate.
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