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A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
- A. A prescribed consultation
- B. The client's vital signs
- C. The client's name
- D. The client's code status
Correct Answer: D
Rationale: The correct answer is D: The client's code status. In the background portion of an SBAR report, the nurse should include the client's code status to inform the receiving unit about the client's preferences for resuscitation in case of an emergency. This information is crucial for providing appropriate and individualized care.
A: A prescribed consultation is typically included in the assessment or recommendations sections of the SBAR report, not the background.
B: The client's vital signs are typically included in the assessment section to provide current physiological data.
C: The client's name is already known and is not necessary in the background portion of the report.
E, F, G: These choices are not applicable to the background portion of the SBAR report.
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A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
- A. Pharmacist
- B. Respiratory therapist
- C. Social worker
- D. Child protective services
Correct Answer: C
Rationale: A social worker can connect the family with financial resources to obtain the nebulizer, addressing the affordability issue.
A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?
- A. Candidiasis
- B. Gonorrhea
- C. Human papillomavirus
- D. Trichomoniasis
Correct Answer: B
Rationale: Gonorrhea is a reportable STI due to its serious long-term health impacts and public health implications, requiring notification to track and control spread.
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
- B. I will have a client who is on airborne precautions wear a mask when out of her room.
- C. I will wear an N95 respirator mask when caring for a client who is on droplet precautions.
- D. I will place a client who has compromised immunity in a negative-pressure airflow room.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of airborne precautions. Airborne precautions require clients to wear a mask when leaving their room to prevent the spread of infectious agents through the air. This statement aligns with the principle of protecting others from exposure.
Explanation for other choices:
A - Incorrect: Visitors, not clients, should wear masks on contact precautions to prevent the spread of infection to the client.
C - Incorrect: N95 respirator masks are used for airborne precautions, not droplet precautions.
D - Incorrect: Negative-pressure airflow rooms are used for clients on airborne precautions, not those with compromised immunity.
Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?
- A. Use clean gloves rather than sterile gloves for colostomy care.
- B. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
- C. Return unused supplies from the bedside to the unit's supply stock.
- D. Wait to dispose of sharps containers until they are completely full.
Correct Answer: C
Rationale: The correct answer is C: Return unused supplies from the bedside to the unit's supply stock. This action helps reduce waste by ensuring that supplies are not being unnecessarily discarded. By returning unused supplies, the unit can minimize unnecessary expenditures on restocking items that could have been used if properly managed. Additionally, it promotes efficient resource utilization and cost savings by preventing duplicate purchases.
Incorrect choices:
A: Using clean gloves rather than sterile gloves for colostomy care may compromise patient safety and increase the risk of infection.
B: Storing opened bottles of normal saline in a refrigerator for up to 48 hours may lead to contamination and compromise patient safety.
D: Waiting to dispose of sharps containers until they are completely full may increase the risk of needle-stick injuries and pose safety hazards.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.