Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

Does not let patient know that nurse is assessing respirations.

Auscultating heart sounds using bell of stethoscope.

Assessing both carotid pulse sites at the same time.

Cleaning stethoscope between patient assessments.

Answer and Explanation

The Correct Answer is C

Choice A rationale
It is a common practice for nurses to assess a patient’s respirations without explicitly stating so. This is because patients may alter their breathing pattern if they know it’s being observed.
Choice B rationale
Auscultating heart sounds using the bell of the stethoscope is a standard practice in nursing. The bell of the stethoscope is used specifically to listen to low-frequency sounds such as heart murmurs.
Choice C rationale
Assessing both carotid pulse sites at the same time is dangerous and should be avoided. This action can lead to reduced blood flow to the brain, possibly causing the patient to faint or experience a decrease in cerebral blood flow.
Choice D rationale
Cleaning the stethoscope between patient assessments is a recommended practice to prevent the spread of infections.

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Correct Answer is D

Explanation

Choice A rationale
Intuition refers to understanding or knowing something without the need for conscious reasoning. It doesn’t fit in this context as the nurse’s actions are deliberate and based on the patient’s needs.
Choice B rationale
Apathy refers to a lack of interest, enthusiasm, or concern. It is the opposite of what the nurse is demonstrating. The nurse is showing concern for the patient’s situation and taking action to help.
Choice C rationale
Empathy refers to the ability to understand and share the feelings of another. While empathy may motivate the nurse’s actions, it does not fully describe the action of contacting a social worker to assist the patient.
Choice D rationale
Advocacy refers to the act of pleading for, supporting, or recommending a course of action. The nurse is advocating for the patient by recognizing their needs and seeking assistance from a social worker.

A. Mrs. S is a 60-year-old patient with appendicitis. B. She is post-appendectomy. C. Could we get an order for additional pain medication? D. Her pain is rated 10/10 on a numerical scale.

Correct Answer is C

Explanation

Choice A rationale
This choice provides information about the patient’s condition, which corresponds to the “Situation” in SBAR123.
Choice B rationale
This choice provides background information about the patient’s medical history, which corresponds to the “Background” in SBAR123.
Choice C rationale
This choice is asking for an order for additional pain medication, which corresponds to the “Recommendation” in SBAR123. In the SBAR communication model, the “Recommendation” is where the nurse would suggest a course of action or ask for an order.
Choice D rationale
This choice provides an assessment of the patient’s pain level, which corresponds to the “Assessment” in SBAR123. In the SBAR model, the “Assessment” is where the nurse would share their analysis or what they think about the situation.

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Which of the following actions by the new nurse requires immediate intervention by the experienced nurse?

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Naxlex Comprehensive Predictor Exams

The nurse observes that a patient is experiencing absolute homelessness. The nurse contacts a social worker to assist the patient with resources. Which term best describes the nurse’s actions?

Correct Answer is D

Explanation

In the context of SBAR Communication, which part of the following message corresponds to the “A” in SBAR?

Correct Answer is C

Explanation

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