For each entry below, choose the component of SBAR that it most accurately represents.
Documentation entry: "The patient has a fractured right tibia with a cast that was applied 2 days ago.
The nurse requests that the primary health provider examine the patient.
The patient reported his pain as a 7 on a 0-10 pain scale 1 hour after he received Norco 10mg PO. The patient's toes are cool and pale, and the patient reports that the foot feels numb.”.

Situation, Background, Assessment, Recommendation.

Background, Situation, Recommendation, Assessment.

Assessment, Situation, Background, Recommendation.

Recommendation, Assessment, Situation, Background.

Answer and Explanation

The Correct Answer is A

Choice A rationale

"The patient has a fractured right tibia with a cast that was applied 2 days ago" provides the Background, giving relevant history about the patient's current condition. "The nurse requests that the primary health provider examine the patient" is the Recommendation, suggesting a course of action based on the assessment. "The patient reported his pain as a 7 on a 0-10 pain scale 1 hour after he received Norco 10mg PO" describes the Situation, highlighting the current problem or change in condition. "The patient's toes are cool and pale, and the patient reports that the foot feels numb" is the Assessment, presenting the nurse's findings and interpretation of the patient's status.

Choice B rationale

This option incorrectly assigns the documentation entries to the SBAR components. The fractured tibia and cast history are background, not the immediate situation. The pain report after medication is the situation, not background. The recommendation is correctly identified, but the cool, pale, numb toes are the assessment, not the recommendation.

Choice C rationale

This option misidentifies the components. The cool, pale, numb toes are assessment findings, not the situation. The pain report after medication is the situation, not background. The fractured tibia and cast history are background, not the assessment. The request for provider examination is the recommendation.

Choice D rationale

This option incorrectly orders the SBAR components. The request for provider examination is the recommendation, not the situation. The cool, pale, numb toes are the assessment, not the background. The pain report after medication is the situation. The fractured tibia and cast history are background. .

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Correct Answer is B

Explanation

Choice A rationale

Increased technology awareness might be a consequence of EHR implementation, but it is not a primary advantage in terms of direct impact on patient care or healthcare delivery efficiency. The focus is on leveraging technology for improved outcomes.

Choice B rationale

EHRs facilitate seamless information sharing among healthcare providers, reducing reliance on paper-based records and improving coordination of care. This enhanced communication can lead to better-informed decision-making, reduced errors, and improved patient safety and outcomes.

Choice C rationale

The need for frequent technology updates can be a challenge associated with EHRs, requiring ongoing investment of time and resources for maintenance and training. This is a potential drawback rather than an advantage of electronic systems.

Choice D rationale

Required system changes, such as upgrades or modifications, can be disruptive and demand significant effort from healthcare organizations. While necessary for maintaining system functionality, they are not considered an inherent advantage of using EHRs.

A. Patient will report increased activity tolerance within 4 days. B. Patient will have improved nutritional intake in 3 days, as evidenced by eating 75% of a protein-rich meal and a 1-1.5 lb weight gain. C. Impaired physical mobility related to extreme weakness as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating. D. Impaired skin integrity due to the patient being lazy as evidenced by a 5cm x 2cm x 1/2 cm stage III ulcer noted on the coccyx, an unstageable wound on the left heel, and a reddened area on the right elbow.

Correct Answer is C

Explanation

Choice A rationale

This statement is written as a patient outcome, not a nursing diagnosis. A nursing diagnosis identifies a patient problem based on assessment data. Outcome statements describe the desired change in patient status as a result of nursing interventions and should be specific, measurable, achievable, relevant, and time-bound (SMART).

Choice B rationale

Similar to Choice A, this statement describes a desired patient outcome with specific criteria. While it includes evidence of improvement, it does not identify the underlying nursing diagnosis or the "related to" factor causing the potential nutritional deficit. A nursing diagnosis requires identifying the problem, its cause, and supporting evidence.

Choice C rationale

This statement correctly identifies a nursing diagnosis with three parts: the problem ("Impaired physical mobility"), the etiology or related factor ("related to extreme weakness"), and the supporting evidence ("as evidenced by the inability to perform active ROM exercises, inability to transfer from bed to chair, and use of a walker when ambulating"). This structure is characteristic of an accurate nursing diagnosis.

Choice D rationale

This statement presents an inaccurate and judgmental related factor ("due to the patient being lazy"). Nursing diagnoses should be based on physiological, psychological, sociological, or spiritual responses to health conditions or life processes, not on subjective or potentially stigmatizing attributions. Additionally, the evidence provided describes the skin breakdown but the stated cause is inappropriate and unprofessional.

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Naxlex Comprehensive Predictor Exams

A nurse is discussing the advantages and challenges of electronic health records (EHRS) with a newly licensed nurse.Which of the following should the nurse include as an advantage?

Correct Answer is B

Explanation

An example of an appropriate nursing diagnosis is:

Correct Answer is C

Explanation

With whom should a nurse share her password for access to the facility's computer system?

Convert 4:38 am to military time.

The client in room 108 has been prescribed new pain medication.A nurse is providing change-of-shift report to the oncoming nurse.Which of the following information should the nurse include in the report?

The nursing process is best defined as a framework for the organization of individualized nursing care.

The establishment of priorities of care during the planning phase of the nursing process often uses the framework of:

The documentation that reflects implementation is:

A charge nurse is reviewing the documentation completed by a newly licensed nurse.Which of the following entries should the charge nurse recommend for revision?