The practical nurse (PN) notifies the healthcare provider about the client's condition using the situation, background, assessment, recommendation (SBAR) format. Which information should the PN provide first?
Last dose of antihypertensive medication.
0.9% normal saline infusing at 75 mL/hour.
Current blood pressure is 80/48 mm Hg.
Emergent cholecystectomy 24 hours ago.
The Correct Answer is C
A. Last dose of antihypertensive medication: Medication history fits under “Background,” not first.
B. 0.9% normal saline infusing at 75 mL/hour: Part of “Background,” not first.
C. Current blood pressure is 80/48 mm Hg: The “Situation” includes the urgent current problem, which is given first in SBAR.
D. Emergent cholecystectomy 24 hours ago: Part of “Background,” not first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Collect ear drainage for culture:
May be indicated if ordered, but not routine before instillation of drops.
B. Warm the drops to room temperature:
Prevents dizziness or nausea from instilling cold drops and promotes comfort.
C. Don sterile gloves to instill the drops:
Clean technique is used for otic medications, not sterile gloves.
D. Insert the dropper into the ear canal:
Risk of trauma and contamination; dropper should remain above canal opening.
Correct Answer is B
Explanation
A. Red streaks from wound: Could indicate lymphangitis but not immediately life-threatening.
B. Urine output 20 mL/hour: Indicates possible septic shock with decreased renal perfusion - urgent finding.
C. Purulent wound drainage: Suggests infection but expected in an infected bite; not immediately life-threatening.
D. Blood pressure 100/60 mm Hg: Low-normal BP; not yet critical unless accompanied by other shock signs.
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