The practical nurse (PN) notifies the healthcare provider about client information using the Situation. Background, Assessment, Recommendation (SBAR) technique. Which information should the PN provide first?
A 26-year-old client
Intravenous fluids infusing at 75 mL/hour.
Blood pressure is 80/48 mmHg.
Cholecystectomy 24 hours ago.
The Correct Answer is C
A. A 26-year-old client: Identifying the client is important but is not the most urgent information when using SBAR. It provides context but comes after the immediate concern.
B. Intravenous fluids infusing at 75 mL/hour: While IV fluids are relevant background information, they do not indicate the acute problem that requires immediate attention.
C. Blood pressure is 80/48 mmHg: In the SBAR framework, the “Situation” should include the most urgent and critical information. Hypotension is a potentially life-threatening finding that must be communicated first to prompt timely intervention.
D. Cholecystectomy 24 hours ago: Surgical history is part of the background information and provides context for the current situation, but it is secondary to the acute vital sign abnormality.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Assess skin appearance and elasticity: This assessment helps evaluate hydration status but does not directly relate to the foul-smelling, cloudy urine, which may indicate a urinary tract infection (UTI).
B. Observe the feet and legs for swelling: Peripheral edema is more related to fluid retention or kidney dysfunction, but the immediate concern with cloudy, foul-smelling urine is potential infection, not edema.
C. Ask the client about urinary frequency: Changes in urinary frequency, urgency, or discomfort are key symptoms of a UTI. Gathering this information helps identify the extent of the urinary problem and guides further intervention.
D. Palpate the bladder area for distention: Bladder palpation assesses retention, which is useful in some urinary issues, but it does not directly evaluate infection or correlate with foul-smelling, cloudy urine.
Correct Answer is D
Explanation
A. Convey that their loved one's condition is very critical, and there has been no response in the last 24 hours: While accurate, providing detailed prognostic information or implying imminent death is beyond the PN’s scope and may cause unnecessary distress.
B. Relay that the nurses have not been able to arouse the client and the healthcare provider knows the outcome: Sharing partial or speculative information can lead to confusion and anxiety. The PN should avoid giving definitive prognoses.
C. Explain the client's extremely critical condition and ask if funeral arrangements have been made: Discussing end-of-life arrangements is inappropriate for the PN to initiate and may be distressing and premature without guidance from the healthcare team.
D. Refer the family to the charge nurse to discuss the client's condition in a family conference: The charge nurse or healthcare provider is responsible for providing detailed updates and supporting the family. Referring the family ensures accurate information is given in a controlled, supportive setting, aligning with professional scope and ethical practice.
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