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.

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Correct Answer is D

Explanation

Illness in one family member can affect the other family members. This is because family-centered nursing care recognizes that the family is the basic unit of society and that each member's health influences the whole family's health. Family-centered nursing care also involves collaborating with the family to provide care that meets their needs, preferences, and values.

Choice A is wrong because the nurse does not provide family-centered nursing care to avoid the client’s loneliness. Loneliness is a psychosocial need, not a physiologic one, and it can be addressed by other means than involving the family.

Choice B is wrong because the client’s compliance with medical instructions is not the primary goal of family-centered nursing care. Compliance is influenced by many factors, such as motivation, education, culture, and trust, and it may not always depend on the family’s involvement.

Choice C is wrong because the family’s willingness to listen to instructions is not the main reason for providing family-centered nursing care. The nurse should respect the family’s autonomy and decision-making, and not impose instructions that may conflict with their beliefs or values.

A. “Older adults often fear becoming addicted to pain medications.”. B. “Older adults often take numerous drugs which can cause interactions with pain medications.”. C. “Confusion and delirium can be a more common reaction to certain pain medications in the elderly.”. D. “Older adults tolerate the same dosage as do younger individuals.”.

Correct Answer is ["D"]

Explanation

Older adults do not have a different pain mechanism and do not feel it as much as younger individuals. This statement is false and indicates the need for further education regarding pain management in older adults.

Some possible explanations for the other choices are:

Choice A is true because older adults often fear becoming addicted to pain medications and may underreport or deny their pain.

Choice B is true because older adults often take numerous drugs that can cause interactions with pain medications and increase the risk of adverse effects.

Choice C is true because confusion and delirium can be a more common reaction to certain pain medications in the elderly, especially opioids and benzodiazepines.

Normal ranges for vital signs in older adults are similar to those in younger adults, except for blood pressure, which may be higher due to arterial stiffness. The normal range for blood pressure in older adults is 120/80 to 140/90 mm Hg.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing nursing care to a client, the nurse provides family-centered nursing care. What is the best rationale for this nursing action?

Correct Answer is D

Explanation

Which statement by the student nurse indicates the need for further education regarding pain management in older adults? (Select all that apply).

Correct Answer is ["D"]

Explanation

Which assessment finding would be considered normal in an elderly client?

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