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The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
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The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
- A. A 40-week pregnant client attached to the fetal monitor having late decelerations.
- B. A 39-week pregnant client in labor with contractions 3 minutes apart.
- C. A 33-week pregnant client with triplets who is on bed rest.
- D. A 26-week pregnant client who is having Braxton Hicks contractions.
Correct Answer: A
Rationale: Late decelerations at 40 weeks (A) indicate fetal distress, requiring the most experienced nurse for close monitoring and potential intervention. Active labor (B), preterm triplets (C), and Braxton Hicks (D) are less critical or stable, suitable for less experienced staff.
The charge nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task would be appropriate to delegate to the UAP?
- A. Collecting a urine specimen from an indwelling urinary catheter.
- B. Increase nasal cannula oxygen for a client by one liter a minute.
- C. Record how much drainage is in the suction cannister.
- D. Remove a nitroglycerin patch before giving a bath.
Correct Answer: A
Rationale: Collecting a urine specimen from an indwelling catheter (A) is within the UAP’s scope with proper training. Adjusting oxygen (B), recording drainage (C), and removing a medicated patch (D) involve clinical judgment or medication administration, reserved for nurses.
The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
The nurse is planning a staff education program about conflict resolution strategies. It is appropriate for the nurse to identify that compromising in a conflict may result in
- A. incomplete satisfaction of both parties’ concerns.
- B. appeasing an individual by self-sacrificing.
- C. suppression of thoughts and feelings.
- D. satisfaction of an individual’s interest regardless of the impact on others.
Correct Answer: A
Rationale: Compromising in conflict (A) often results in incomplete satisfaction for both parties, as each gives up something to reach agreement. Appeasing (B) involves self-sacrifice, suppression (C) avoids conflict, and individual satisfaction (D) reflects winning, not compromising.
The nurse notices an unlicensed assistive personnel (UAP) passing by several call lights during the shift. Which initial action should the nurse take?
- A. Approach the UAP about the behavior.
- B. Report unsafe behavior to the charge nurse.
- C. File an incident report due to safety risk.
- D. Ask another UAP to help cover this UAP's patient load.
Correct Answer: B
Rationale: Approaching the UAP (B) initially allows for clarification and correction of the nurse can address the behavior, promoting teamwork and addressing potential safety issues.. Reporting to the charge nurse (A) or filing an incident report (C) escalates prematurely. Assigning another UAP (D) does not address the root cause.