Nokea
The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to a support group upon discharge. This statement represents which part of the ISBAR handoff report?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: D
Rationale: Suggesting a support group referral (D) is a recommendation, part of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handoff, proposing actions for ongoing care. It is not situation (A), background (B), or assessment (C).
You may also like to solve these questions
The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply.
- A. As needed (PRN) medications that were administered
- B. Normal assessment findings for the shift
- C. Normal laboratory results
- D. Scheduled medications that were administered
- E. Abnormal vital signs
Correct Answer: A, D, E
Rationale: PRN medications (A), scheduled medications (D), and abnormal vital signs (E) are critical for care continuity, per ISBAR standards. Normal findings (B) and normal lab results (C) are less essential unless they impact care.
The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.
The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a 'wrong surgery' because this possible error was caught in time. What is your priority action as the nurse manager?
- A. Praise the staff for catching these near misses before a surgical error occurs.
- B. Investigate and explore this near miss.
- C. Investigate and explore this medical error.
- D. Report the nature and frequency of these medical errors to the State Department of Health.
Correct Answer: B
Rationale: Investigating and exploring the near miss (B) is the priority to identify root causes and prevent future errors. These are near misses, not medical errors (C, D), as no harm occurred. Praising staff (A) is supportive but secondary to addressing the systemic issue.