The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Prescription for ceftriaxone PO every 12 hours.

A 26-year-old client.

Blood pressure is 80/48 mm Hg.

Admitted after a motor vehicle collision.

Answer and Explanation

The Correct Answer is C

A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.

B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.

C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.

D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.

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Correct Answer is C

Explanation

A. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.

B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.

C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.

D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.

A. Don gloves. B. Apply a surgical mask. C. Put on an isolation gown. D. Wash hands.

Correct Answer is D,C,B,A

Explanation

Correct order: D C B A

Washing hands is the first step before any PPE is applied to ensure cleanliness and prevent the introduction of pathogens.
Putting on the isolation gown is the next step, as it protects the nurse's clothing from exposure to potentially infectious materials.
Applying a surgical mask is the next step to protect the nurse from airborne or droplet transmission.
Donning gloves is the final step, as gloves should be put on last to protect the hands while providing direct care, especially when dealing with wound care.

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The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse is caring for a client in isolation who requires wound care. The nurse should prepare to enter the room by performing these actions in which order? (Arrange with the first step on top and the last step at the bottom.)

Correct Answer is D,C,B,A

Explanation

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