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

“I feel uncomfortable praying with you, but I will find someone who won’t feel that way.” This statement by the nurse would best meet the client’s spiritual needs because it acknowledges the nurse’s own boundaries and feelings while also respecting the client’s request and finding a way to fulfill it.

Some possible explanations for why the other choices are wrong are:

Choice A is wrong because it does not address the client’s request to pray together and it assumes that the client wants a Bible without asking.

Choice B is wrong because it implies that the nurse does not want to pray with the client and that the client’s visitors would be more suitable for this task, which could make the client feel rejected or unsupported.

Choice C is wrong because it directly rejects the client’s request and discloses the nurse’s personal beliefs, which could create a sense of disconnection or conflict between the nurse and the client.

A. “I don’t know.Biopsies are often negative.”. B. “I can’t say. Did your health care provider tell you?”. C. “No one knows yet. I’d like to hear what you are thinking.”. D. “Everyone thinks about that. Don’t worry until the final report is back.”.

Correct Answer is C

Explanation

I’d like to hear what you are thinking.” This response by the nurse would most likely prompt the client to elaborate on their concerns because it acknowledges the uncertainty of the situation and invites the client to share their feelings and thoughts.

It also shows empathy and respect for the client’s perspective.

Choice A is wrong because it may give false reassurance or minimize the client’s anxiety. Biopsies are not always negative and the nurse cannot predict the outcome.

Choice B is wrong because it may imply that the nurse is avoiding the question or shifting the responsibility to the health care provider.

It also does not address the client’s emotional state or encourage communication.

Choice D is wrong because it may dismiss the client’s fears or imply that they are irrational. It also does not explore the client’s understanding of the procedure or the possible results.

A uterine biopsy is a procedure that involves removing a small piece of tissue from the lining of the uterus (endometrium) for examination under a microscope. It is usually done to diagnose abnormal bleeding, infections, or cancer. The normal range of endometrial thickness varies depending on the menstrual cycle, age, and hormonal status of the woman.

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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

A nurse is reluctant to pray when a client requests to pray together. Which statement by the nurse would best meet the client’s spiritual needs?

Correct Answer is D

Explanation

Following a uterine biopsy, a client asks a nurse, “Do you think I have cancer?” Which response by the nurse would most likely prompt the client to elaborate on their concerns?

Correct Answer is C

Explanation

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