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A nurse enters a patient's room and finds them vomiting bright red blood. After taking vital signs, the nurse communicates the event to the health care provider using the SBAR format. Which information will the nurse include in the 'A' portion of the SBAR communication?
- A. Admitted with peptic ulcer and bleeding disorder
- B. Found vomiting in bathroom
- C. Anti-ulcer medication recommendation
- D. Vital signs, oxygen saturation, bright red emesis
Correct Answer: D
Rationale: The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments.
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A nurse enters the room of a patient with cancer. The patient is crying and states, 'I feel so alone.' How will the nurse best communicate a therapeutic response?
- A. The nurse stands at the patient's bedside and states, 'I understand how you feel. My mother said the same thing when she was ill.'
- B. The nurse places a hand on the patient's arm and states, 'You feel so alone.'
- C. The nurse stands in the patient's room and asks, 'Why do you feel so alone? Your wife has been here every day.'
- D. The nurse holds the patient's hand and asks, 'Tell me what feeling so alone is like for you?'
Correct Answer: D
Rationale: The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely.
A nursing student is preparing to administer morning care to a patient. What question by the student is most important to ask?
- A. Would you prefer a bath or a shower?
- B. May I help you with a bed bath now or later this morning?
- C. I will be giving you your bath. Do you use soap or shower gel?
- D. I prefer a shower in the evening. When would you like your bath?
Correct Answer: B
Rationale: The nurse should ask permission to assist the patient with a bath. This allows for patient preferences and consent for care that involves entering the patient's personal space.
A patient states, 'I have been experiencing complications of diabetes.' What question will the nurse use to elicit additional information?
- A. Do you take two injections of insulin to prevent complications?
- B. Are you using diet and exercise to help regulate your blood sugar?
- C. Have you been experiencing the complications of neuropathy?
- D. Can you tell me about the complications you've experienced?
Correct Answer: D
Rationale: Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments.
A nurse says to their nurse manager, 'I need the day off, and you didn't give it to me!' The manager replies, 'I wasn't aware you needed the day off, and it isn't possible since staffing is inadequate.' How could the nurse best modify the communication for a more positive interaction?
- A. I placed a request to have 8th of August off for a doctor's appointment, but I'm scheduled to work.
- B. Could I make an appointment to discuss my schedule with you? I requested the 8th of August off for a doctor's appointment.
- C. I will need to call in on the 8th of August because I have a doctor's appointment.
- D. Since you didn't give me the 8th of August off, will I need to find someone to work for me?
Correct Answer: B
Rationale: Effective communication involves sending clear, nonthreatening, and respectful information to the receiver. The nurse identifies the subject of the meeting and determines a mutually agreed upon time.
The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene?
- A. I am sure everything will be fine; you have nothing to worry about.
- B. When you return from surgery, you'll need to cough and deep breathe.
- C. Many people on this unit have had that procedure with good success.
- D. You seem fearful, can I answer any questions about the procedure?
Correct Answer: A
Rationale: Telling a patient that everything will be fine is a clich?©. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition.