The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?

“The client status is deteriorating. I feel you should come now.”.

“The client has hypoxemia after 10 minutes on a rebreather mask.”.

“The PaO2 is 55, PaCO2 is 90, HCO3 is 26.”.

“The client has a history of chronic obstructive pulmonary disease and was admitted with pneumonia.”.

Answer and Explanation

The Correct Answer is B

The nurse should make the statement “The client has hypoxemia after 10 minutes on a rebreather mask.” first. This is because SBAR (Situation- Background-Assessment-Recommendation) is a communication tool that helps provide essential, concise information, usually during crucial situations. The first component of SBAR is Situation, which is a concise statement of the problem.

The nurse should state the most urgent and relevant problem first, which is the client’s hypoxemia.

Choice A is wrong because it is not a clear statement of the situation.

It is vague and does not provide specific information about the client’s condition or vital signs.

It also expresses the nurse’s feeling rather than an objective assessment.

Choice C is wrong because it is part of the Assessment component of SBAR, not the Situation.

It provides numerical data about the client’s blood gas analysis, but it does not state the problem or the reason for calling the healthcare provider.

Choice D is wrong because it is part of the Background component of SBAR, not the Situation.

It provides pertinent and brief information related to the situation, such as the client’s medical history and diagnosis, but it does not state the current problem or concern.

Normal ranges for blood gas analysis are:

PaO2: 80-100 mmHg
PaCO2: 35-45 mmHg
HCO3: 22-26 mEq/L

Hypoxemia is defined as a low level of oxygen in the blood, usually below 60 mmHg.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

“I apologize for not hearing you say that. Is there a better day for you?”.

This response shows empathy and respect for the client’s feelings and preferences.

It also invites the client to collaborate on finding a solution that works for both parties. Choice A is wrong because it is rude and defensive.

It does not acknowledge the client’s frustration or offer any alternatives. Choice C is wrong because it is dismissive and paternalistic.

It does not respect the client’s autonomy or consider the client’s reasons for not being able to come back on Friday.

Choice D is wrong because it is persuasive and manipulative.

It does not address the client’s concerns or explore other options.

The nurse-client relationship is based on trust, respect, and collaboration.

The nurse should use therapeutic communication skills to maintain a positive rapport with the client and promote their health and well-being.

A. Increased heart rate. B. Decreased blood pressure. C. Increased temperature. D. Hypoactive muscle responses. E. Alert and oriented.

Correct Answer is ["A","B"]

Explanation

Increased heart rate and decreased blood pressure are common signs of dehydration, as the body tries to compensate for the fluid loss by increasing the heart rate and lowering the blood pressure.

Choice C is wrong because increased temperature is not a typical symptom of dehydration, although it can be a cause of it.

Choice D is wrong because hypoactive muscle responses are not related to dehydration, but rather to neurological or muscular disorders.

Choice E is wrong because alert and oriented is the normal mental status for most people, and dehydration can cause confusion and disorientation in severe cases.

Normal ranges for heart rate and blood pressure vary depending on age, gender, physical activity, and other factors, but generally they are:

Heart rate: 60 to 100 beats per minute for adults
Blood pressure: less than 120/80 mmHg for adults

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse calls the healthcare provider using SBAR Communication. Which statement should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the clinic states, “I already told you I can’t come back on Friday.” Which response by a nurse would be likely to repair the client-nurse relationship?

Correct Answer is B

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?

The nurse reviews the healthcare provider’s orders for a client with bacterial pneumonia. Which of the following should the nurse carry out first?

Which instruction should a nurse give to a client taking alendronate (Fosamax) for osteoporosis?

The nurse has developed a pain management plan for a client who has a history of opioid drug abuse. Which of the following statements by the client demonstrates understanding of the pain management plan?

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

A nurse is teaching a client about preparation for a barium enema. What client statement indicates the client requires further reinforcement of teaching?

What is the best question to evaluate a client’s understanding of infection control measures while receiving treatment for hepatitis A?

A client has lorazepam prescribed before surgery and refuses the injection. If the nurse administers the scheduled injection despite the client’s lack of consent, which term best describes the nurse’s action?