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.”.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Albumin is a protein that is made by the liver and helps maintain fluid balance in the
body. The normal range for albumin is 3.5 to 5.5 g/dL or 35-55 g/liter. A low albumin level can indicate malnutrition, liver disease, kidney disease, inflammation, or other conditions that affect protein synthesis or loss.
A client diagnosed with Imbalanced Nutrition: Less than Body Requirements would be expected to have a low albumin level due to inadequate protein intake or absorption.
Choice A is wrong because hemoglobin = 14.2 g/dL is within the normal range for males, which is 13.2 to 16.6 g/dL.
Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. A low hemoglobin level can indicate anemia, which can be caused by blood loss, iron deficiency, vitamin B12 deficiency, or other conditions that affect red blood cell production or destruction.
Choice B is wrong because potassium = 4.2 mEq/L is within the normal range for adults, which is 3.5 to 5 mEq/L.
Potassium is an electrolyte that helps regulate fluid balance, nerve impulses, and muscle contractions. A low potassium level can indicate dehydration, diarrhea, vomiting, diuretic use, or other conditions that cause potassium loss. A high potassium level can indicate kidney disease, adrenal insufficiency, acidosis, or other conditions that cause potassium retention.
Choice D is wrong because creatinine = 0.8 mg/dL is within the normal range for adults, which is 0.6 to 1.2 mg/dL.
Correct Answer is C
Explanation
Motrin is a brand name for ibuprofen, which is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs can cause renal toxicity, especially in older adults and patients with renal disease.
Therefore, the nurse should be most concerned about this medication and its potential adverse effects on the patient’s kidney function.
Choice A is wrong because digoxin is a cardiac glycoside that is used to treat heart failure and atrial fibrillation. Digoxin has a narrow therapeutic index and can cause toxicity if the dose is too high or if the patient has hypokalemia. However, digoxin does not directly affect the kidneys and can be safely used in patients with renal disease if the dose is adjusted according to the patient’s creatinine clearance.
Choice B is wrong because levothyroxine is a synthetic thyroid hormone that is used to treat hypothyroidism. Levothyroxine does not have any major interactions with the kidneys and can be used in patients with renal disease without dose adjustment.
Choice D is wrong because Tylenol is a brand name for acetaminophen, which is an analgesic and antipyretic drug. Acetaminophen does not have any anti-inflammatory effects and does not affect the kidneys at therapeutic doses. However, acetaminophen can cause hepatotoxicity if the dose exceeds 4 g per day or if the patient has liver disease or alcohol abuse.
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