The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which clinical situation?
When preparing to discharge the client home
When documenting the care that was provided to a client whose condition recently deteriorated
When transferring a client from the emergency department to the acute care unit
When reporting to a client's family member or significant other
The Correct Answer is C
A. Discharge preparation involves teaching and planning, but ISBARR is not typically used.
B. Documentation uses standard medical record formats, not ISBARR.
C. ISBARR is designed for clear, structured communication between healthcare providers, especially during client handoffs like transferring from the emergency department to acute care.
D. Reporting to family uses a different communication style focused on support and explanation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A face tent delivers oxygen but is typically used for clients who cannot tolerate masks and usually provides variable oxygen concentrations.
B. A nasal cannula is appropriate for delivering low concentrations of oxygen (typically 24% to 44%) and allows the client to eat, talk, and move more easily. It is commonly used for clients who need low-flow oxygen therapy, such as those with asthma.
C. A nonrebreather mask delivers high concentrations of oxygen (up to 100%) and is not suitable when only low oxygen concentrations are needed.
D. A simple mask delivers moderate oxygen concentrations (35% to 50%) and is generally used when higher oxygen levels are required than with a nasal cannula.
Correct Answer is B
Explanation
A. While involving a spiritual advisor may be helpful, the nurse’s priority is to ensure the client is fully informed before decisions are made.
B. Providing all relevant information allows the client to weigh risks and options and make an informed decision respecting their beliefs.
C. Forcing information or pressuring the client disregards their autonomy and beliefs.
D. Having the client sign refusal without thorough discussion does not support informed consent or shared decision-making.
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