The nurse is caring for a client and the following sequence of events occur:. 1428: BP: 88/36 mm Hg. 1430: Dr. Jones paged.

1445: No return call from Dr. Jones.

1450: BP 90/40 mm Hg. 1455: Dr. Jones paged and charge nurse notified.

1505: No return call from Dr. Jones.

What should the nurse document in the patient's chart regarding the sequence of events described above?

Dr. Jones paged at 1430 and 1455 about low blood pressure readings.

No return call from Dr. Jones.

Patient and family informed that Dr. Jones may not call back.

Dr. Jones paged at 1430 of patient's BP 88/36 mm Hg. Repeat BP at 1450 90/40 mm Hg. Dr. Jones paged at 1455.

No orders received.

Answer and Explanation

The Correct Answer is B

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Correct Answer is C

Explanation

Choice A rationale:

During inhalation, carbon dioxide levels are lower in the alveoli due to the exchange of gases. The higher concentration of carbon dioxide is found in the blood, which diffuses into the alveoli for elimination during exhalation.

Choice B rationale:

Alveoli do not collapse during the inhalation cycle. Surfactant, a substance produced by type II alveolar cells, reduces surface tension and prevents alveoli from collapsing, ensuring efficient gas exchange.

Choice C rationale:

Oxygen moves from the alveoli to the capillaries, while carbon dioxide moves from the capillaries to the alveoli. This exchange of gases occurs due to differences in partial pressures, facilitating the uptake of oxygen by red blood cells and the removal of carbon dioxide from the body.

Choice D rationale:

Exhaling carbon dioxide is a passive process that does not require significant effort. The respiratory muscles relax during exhalation, allowing the lungs to passively expel carbon dioxide from the body as a waste product of metabolism.

A. "I am calling report on Mr. Jones who is being transferred to your unit today from the emergency room.”. B. "He has swelling of the left knee and it is bruised, red and tender. C. "He is requesting a bed close to the bathroom so he can get to the bathroom easier.”. D. "Mr. Jones has had left knee pain following a motor vehicle accident four days ago.”.

Correct Answer is A

Explanation

Choice A rationale:

In the SBAR method, "S" stands for Situation. This portion of the report includes a brief and concise statement about the patient's current situation or problem. In this case, option A provides a clear and specific statement about the patient's situation, indicating that Mr. Jones is being transferred to another unit from the emergency room. The nurse would identify this statement as the "situation" portion of the SBAR report because it conveys the current status of the patient and the reason for the communication.

Choice B rationale:

Option B discusses the patient's symptoms and condition in detail, focusing on the left knee swelling, bruising, redness, and tenderness. While this information is important, it falls under the "Background" section of the SBAR report, not the "Situation" section. The "Situation" section should provide a brief overview of the patient's current status and the reason for the communication, which choice A accurately conveys.

Choice C rationale:

Option C mentions the patient's request for a specific bed location, which is relevant to the patient's preferences but does not constitute the "situation" portion of the SBAR report. This information is more appropriate for the "Recommendation" or "Request" section of the SBAR communication model.

Choice D rationale:

Option D provides information about the patient's history of left knee pain following a motor vehicle accident four days ago. While this information is important for understanding the patient's background, it does not represent the current situation or reason for the communication. Therefore, it does not fit the "situation" portion of the SBAR report.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement regarding the anatomy and physiology of the respiratory system is correct?

Correct Answer is C

Explanation

A nurse uses the SBAR method to give report about a patient to another unit in the hospital.What statement by the nurse would the nurse identify as the "situation" portion of the SBAR report?

Correct Answer is A

Explanation

The nurse is working on an inpatient surgical unit.Which action by the nurse would be considered inappropriate? Select all that apply.

A patient is experiencing dyspnea.Which intervention(s) would the nurse implement for the patient? Select all that apply.

A nurse is caring for a terminally ill patient with questions regarding end-of-life care options.The nurse provides an informational packet to the patient, and discusses the various care options available.The nurse is demonstrating which professional value?

Which intervention would be appropriate for a client with shortness of breath?

The nurse explains isometric exercises to the patient on the rehabilitation unit.Which explanation provided by the nurse is accurate?

The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.What is the nurse assessing in whole, or part, with this action? Select all that apply.

The nurse measures the client's laceration as 5 inches. How many cm would the nurse document as the laceration length? Round to the nearest tenth place.

The nurse has an order for 27 mg of Augmentin three times daily for a 6-year-old. The pharmacy sends a vial labeled 20 mg/1 mL when reconstituted with 2.3 mL of saline. How many mL will the nurse administer per day?