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.
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Related Questions
Correct Answer is A
Explanation
A. Participating in the client's care within his/her capabilities and desires: Involving the spouse supports coping, emotional connection, and shared decision-making.
B. Information about palliative and hospice care services: Important but may be more helpful once the family has processed the diagnosis further.
C. Consultation with the case manager and hospital chaplain: Useful but not the most immediate supportive intervention.
D. Visiting after procedures are done to avoid seeing the client in pain: Avoidance can increase anxiety and feelings of helplessness.
Correct Answer is D
Explanation
A. Inform the manager that the facility will have to assume responsibility for incidents related to staffing: This is confrontational and does not address immediate care needs.
B. Refuse to take charge and go home rather than risk working in an unsafe situation: Abandoning patients is unethical and could have legal consequences.
C. Assign some tasks usually performed by the additional PN to the UAP who is normally on the wing: UAPs cannot legally take on PN duties; this is unsafe.
D. Prioritize assessment of safety issues in addition to administration of daily medication: When short-staffed, prioritize safety and essential tasks to ensure client well-being.
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