The nurse is notifying the HCP of the client's change in status using the SBAR format. In which order should the nurse place the statements?

1. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client."

2. "The client is deteriorating, and I'm afraid the client is going to arrest."

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)."

4. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask."

2,4,3,1

3.4.2.1

4.3.2.1

3.4.1.2

Answer and Explanation

The Correct Answer is A

1. "The client is deteriorating, and I'm afraid the client is going to arrest." This statement provides a clear and urgent indication of the client's current status, emphasizing the severity of the situation and the immediate concern for potential cardiac arrest. The nurse’s choice of language conveys a sense of urgency that is crucial for the HCP to understand the need for prompt action. In SBAR format, the order is: Situation (2), Background (4), Assessment (3), and Recommendation (1).

2. "The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask." This statement elaborates on the clinical findings and symptoms, giving the HCP a better understanding of the patient's condition and how it is affecting their overall stability. The details about the patient's physical state, such as skin condition and oxygen saturation, highlight the critical nature of the situation.

3. "I am calling about (client name and location). Vital signs are BP=100/50, P=120, RR=30, T=100.4°F (38°C)." This provides the background information, including the patient's vital signs, which is critical for the HCP to evaluate the situation. Clear communication of vital signs establishes a baseline for the HCP to assess the urgency of the clinical scenario and informs potential interventions.

4. "I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate the client." This statement summarizes the recommendation, clearly indicating the action the nurse believes should be taken based on the assessment. It conveys the need for immediate evaluation and care in a higher-acuity setting, ensuring that the HCP understands the recommended next steps in the patient’s management.

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

A. A client who is 1 day postoperative and has a nursing assistant helping him out of bed: While this client is at risk due to being postoperative, the presence of a nursing assistant provides additional support and assistance, which helps mitigate the risk of falling during this transition.

B. An older adult client who is confused and has urinary frequency: This client is at the greatest risk for a fall. Confusion can impair judgment and coordination, and urinary frequency can lead to hurried movements to the bathroom, increasing the likelihood of falls. Older adults are generally more susceptible to falls due to physiological changes, and the combination of confusion and the need for frequent trips to the bathroom heightens this risk significantly.

C. A client with diabetes mellitus who has a leg ulcer: Although this client may have mobility issues related to the leg ulcer, diabetes does not inherently increase the risk for falls as much as confusion and urinary frequency do. The focus would be on wound care rather than immediate fall risk.

D. An adolescent client who has a leg fracture and has been using crutches for the past 2 days: While this client is at risk due to the leg fracture and the use of crutches, they are likely to have received instruction on proper use of the crutches. If the client is following these instructions, the risk may not be as high as that of the confused older adult.

A. Allowing the patient to ambulate independently B. Administering a sedative to keep the patient calm C. Placing the patient in restraints D. Implementing a fall prevention protocol E. Educating the patient on using the call light system

Correct Answer is ["D","E"]

Explanation

A. Allowing the patient to ambulate independently: This intervention is not appropriate for a patient who scores 30 points on the Morse Fall Scale, which indicates a high risk of falling. The patient should be monitored closely and assisted with ambulation to prevent falls.

B. Administering a sedative to keep the patient calm: While it may be important to keep the patient calm, using sedatives should be approached with caution, as they can increase the risk of falls and impair judgment and coordination. This intervention is not the most appropriate approach to fall prevention.

C. Placing the patient in restraints: Restraints should be used only as a last resort and only when necessary to prevent harm to the patient or others. Using restraints can lead to physical and psychological harm and should not be the primary intervention for fall prevention.

D. Implementing a fall prevention protocol: This is the most appropriate intervention for a patient with a high risk of falling. A fall prevention protocol may include measures such as ensuring a clear path, using assistive devices, and conducting regular assessments of the patient's mobility and safety.

E. Educating the patient on using the call light system: This intervention is important for ensuring the patient feels safe and can call for assistance when needed. Educating the patient on the call light system promotes communication and can help prevent falls by encouraging the patient to seek help when they need to move or ambulate.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall?

Correct Answer is B

Explanation

Which of the following interventions is most appropriate for a patient that gets 30 points on the Morse Fall Scale? (Select All that Apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take?

While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do?

Which of the following is a benefit of negative pressure wound therapy (NPWT) for skin wounds?

In a clinical setting, a patient with a chronic wound is scheduled for debridement. Which of the following is the primary purpose of wound debridement?

A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Clients with special needs require specific communication techniques. Which specific communication techniques should a nurse utilize when caring for a client who is cognitively impaired?

A patient is found to have a broken skin on his coccyx that has black eschar covering the base of the wound. How is this wound staged?