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 A

Explanation

A. A 60 year old patient who is on a mechanical ventilator: This patient is at the highest risk for healthcare-acquired infections (HAIs) due to the use of mechanical ventilation. Ventilated patients are susceptible to ventilator-associated pneumonia and other respiratory infections, making them more vulnerable to HAIs.

B. A 65 year old patient who is vegetarian and obese: While obesity can increase the risk for certain complications, being vegetarian does not inherently increase the risk for HAIs. This patient may have some risk factors, but they are not as significant as those associated with mechanical ventilation.

C. A 45 year old patient who smokes a pack of cigarettes a day: Smoking is a risk factor for various health issues, including respiratory infections, but it does not specifically correlate with a higher risk of HAIs in a hospitalized setting compared to a patient on a mechanical ventilator.

D. A 70 year old patient who has a normal WBC count: Although older age can increase the risk for infections, a normal white blood cell count indicates a functioning immune response. Without additional risk factors, this patient would not be considered the most at risk for developing HAIs compared to a ventilated patient.

A. The hot water heater is set at 54°C (130° F). B. Grab bars are installed in the bathroom. C. Area rugs are placed in the living room. D. Medications are stored in a clear bag. E. Dim lighting installed throughout the house.

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

Explanation

A. The hot water heater is set at 54°C (130° F): This temperature poses a risk of burns, especially for a client who may have impaired mobility or sensation due to a stroke. Water temperatures above 49°C (120°F) can cause burns, and 54°C (130°F) increases that risk significantly, making it a safety hazard.

B. Grab bars are installed in the bathroom: This is a safety feature rather than a hazard. Grab bars can help prevent falls and provide support for clients with mobility issues, making them an important aspect of home safety, particularly for someone who has experienced a stroke.

C. Area rugs are placed in the living room: Area rugs can create tripping hazards, especially for clients who may have difficulty with balance or mobility after a stroke. If not secured properly, they can lead to falls, making this a safety hazard.

D. Medications are stored in a clear bag: While storing medications in a clear bag may provide visibility, it does not ensure safety. If the bag is not clearly labeled or is accessible to children or pets, it can pose a risk of accidental ingestion or misuse, thus representing a safety hazard.

E. Dim lighting installed throughout the house: Dim lighting can increase the risk of falls, especially for clients with visual impairments or those who may not be able to navigate their environment safely after a stroke. Proper lighting is essential for ensuring safety and preventing accidents, making this a safety hazard.

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Naxlex Comprehensive Predictor Exams

The nurse assesses patients to determine their risk for healthcare acquired infections. Which hospitalized patient would the nurse consider most at risk for developing this type of infection?

Correct Answer is A

Explanation

A nurse is performing a home safety assessment for a client who has experienced a stroke. Which of the following findings are a safety hazards for the client? (Select All that Apply.)

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

Explanation

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A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect?

A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)

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