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.

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Correct Answer is D

Explanation

A. Airborne: Airborne precautions are used for diseases that can be transmitted through airborne droplet nuclei, such as tuberculosis or measles. Hepatitis C is not transmitted through the air, making airborne precautions unnecessary for this condition.

B. Droplet: Droplet precautions are required for infections spread through respiratory droplets, such as influenza or meningitis. Hepatitis C is not spread via respiratory droplets, so droplet precautions are not applicable.

C. Contact: Contact precautions are necessary for infections that can be transmitted through direct contact with the patient or contaminated surfaces, such as MRSA or C. difficile. While contact precautions may be applied in specific situations involving hepatitis C, they are not the standard precautions for routine care of hepatitis C patients.

D. Standard: Standard precautions are the foundation for infection control practices and are recommended for all patients, regardless of their diagnosis. This includes measures such as hand hygiene, using personal protective equipment (PPE) when necessary, and safe handling of potentially contaminated materials. Since hepatitis C is primarily transmitted through blood and body fluids, standard precautions are appropriate for caring for clients with this condition.

A. Elevate the bed to a position of comfort for the nurse. B. Lock the wheels of the bed and the wheelchair. C. Place the wheelchair at a 90° angle to the bed. D. Acquire the help of several people to lift the client.

Correct Answer is B

Explanation

A. Elevate the bed to a position of comfort for the nurse: While it is important for the nurse to maintain proper body mechanics and comfort during the transfer, the primary focus should be on the safety and comfort of the client. The bed should be elevated to a height that allows for a safe transfer, not just for the nurse's comfort.

B. Lock the wheels of the bed and the wheelchair: This is a crucial safety measure. Locking the wheels prevents both the bed and the wheelchair from moving during the transfer, reducing the risk of falls or injuries for both the client and the nurse. Ensuring stability is essential for a safe and effective transfer.

C. Place the wheelchair at a 90° angle to the bed: While positioning the wheelchair correctly is important, placing it at a 90° angle may not be the best approach for all clients. The wheelchair should generally be positioned close to the bed, either parallel or at a slight angle, to facilitate a smooth transfer and ensure the client's safety.

D. Acquire the help of several people to lift the client: It is typically not necessary to lift the client unless they are unable to assist in the transfer. Instead, proper techniques, such as using a transfer belt or slide board, should be employed to assist the client in moving safely to the wheelchair. Relying on multiple people to lift can also increase the risk of injury to both the client and the staff if not done properly.

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Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement?

Correct Answer is D

Explanation

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate?

Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment?

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

A nurse is caring for a group of clients. The nurse demonstrates adherence to the ethical principle of fidelity by doing which of the following?

The nurse is teaching a client who is preparing for surgery. Which teaching about a Jackson-Pratt drain will the nurse include?

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

A nurse is admitting an older adult from Mumbai, India who is visiting family members in the US. Which of the following would be most appropriate for the nurse to say?

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient?