Nokea
How can a nurse manager best improve hand-off communication among the staff? (SATA)
- A. Attending hand-off rounds to coach and mentor.
- B. Conducting audits of staff using a new template.
- C. Creating a template of topics to include in the report.
- D. Utilizing the SHARE model as a tool for standardizing hand-off reports and other critical communication.
Correct Answer: D
Rationale: The correct answer is D because utilizing the SHARE model helps standardize hand-off reports and communication.
1. S stands for Situation: providing context.
2. H stands for History: outlining relevant information.
3. A stands for Assessment: sharing assessment findings.
4. R stands for Recommendation: suggesting actions.
5. E stands for Explanation: clarifying any questions.
This model ensures all necessary information is communicated effectively. A, B, and C are incorrect because attending hand-off rounds, conducting audits, and creating templates may not ensure standardized communication like the SHARE model does.
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While you are talking with the patient, she becomes confused and begins slurring her words. What would you expect the physician to do?
- A. Assess if the patient had an ischemic or hemorrhagic cerebral vasospasm (CVS).
- B. Administer thrombolytic agent (TPA) since this is within 3 hours of the cerebrovascular accident (CVA).
- C. Tell the patient to go home, get rest, and to call the physician in the morning if the symptoms continue.
- D. Admit the patient and place her on bed rest.
Correct Answer: B
Rationale: Thrombolytics can dissolve clots if administered within the therapeutic window.
A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding indicates a need for immediate action?
- A. Weight gain of 1 kg since the last dialysis session
- B. Blood pressure of 150/90 mm Hg
- C. Potassium level of 6.5 mEq/L
- D. Hemoglobin level of 10 g/dL
Correct Answer: C
Rationale: The correct answer is C: Potassium level of 6.5 mEq/L. High potassium levels in ESRD patients can lead to life-threatening cardiac arrhythmias. Immediate action is needed to prevent complications. A: Weight gain may indicate fluid retention, but it's not an immediate concern. B: Blood pressure is elevated but not an urgent issue. D: Hemoglobin level of 10 g/dL is within the acceptable range for ESRD patients and does not require immediate action.
A client with a spinal cord injury at T6 suddenly reports a pounding headache and blurred vision. What action should the nurse take first?
- A. Administer pain medication as ordered.
- B. Check the client's blood pressure.
- C. Place the client in a supine position.
- D. Increase the client's fluid intake.
Correct Answer: B
Rationale: The correct action is to check the client's blood pressure first. A sudden onset of pounding headache and blurred vision in a client with a spinal cord injury at T6 can indicate autonomic dysreflexia. Checking the blood pressure is crucial as autonomic dysreflexia can lead to severe hypertension, which can result in life-threatening complications such as stroke or seizure. Immediate assessment and intervention are necessary to prevent further harm. Administering pain medication without addressing the underlying cause can exacerbate hypertension. Placing the client in a supine position can worsen symptoms, and increasing fluid intake does not address the immediate issue at hand. Therefore, checking the blood pressure is the priority to identify and manage autonomic dysreflexia effectively.
During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?
- A. I suggest ordering a different pain medication.
- B. This client has allergies to morphine & codeine.
- C. Dr. Smith does not prefer nonsteroidal anti-inflammatory meds.
- D. The client had a vaginal hysterectomy 2 days ago.
Correct Answer: B
Rationale: The correct answer is B because it provides relevant information regarding the client's allergies to morphine and codeine, which is crucial for the physician to know when considering alternative pain medication options. This aligns with the "Background" component of the SBAR format, which includes pertinent patient history.
Choice A is incorrect because it jumps to a solution without providing necessary background information. Choice C is irrelevant to the current situation as it does not address the client's pain management issue. Choice D is also incorrect as it only provides historical information about the type of hysterectomy performed, which is not directly related to the client's current pain management concern.
A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the client's heart failure?
- A. Do you have trouble breathing or chest pain?
- B. Are you able to walk upstairs without fatigue?
- C. Do you awake with breathlessness during the night?
- D. Do you have new-onset heaviness in your legs?
Correct Answer: B
Rationale: The correct answer is B because assessing the client's ability to walk upstairs without fatigue helps determine the extent of heart failure. This question assesses the client's functional capacity and exercise tolerance, which are key indicators of heart failure severity. If the client experiences fatigue while walking upstairs, it indicates decreased cardiac output and potential heart failure progression. Other choices are incorrect as they focus on symptoms (A), nocturnal dyspnea (C), and peripheral edema (D), which may be present in heart failure but do not directly assess the extent of heart failure like exercise tolerance does.