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The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?
- A. Offering therapeutic support to a grieving family.
- B. Obtaining clarification from a client’s healthcare power-of-attorney.
- C. Reporting a change in a client’s condition to the healthcare provider.
- D. Completing discharge teaching to a client and family members.
Correct Answer: C
Rationale: SBAR is for clinical communication.
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A confused older adult client is having trouble sleeping at night and is sometimes found wandering in the hallway. Which nursing intervention should the nurse implement first?
- A. Administer a PRN sedative prescription.
- B. Leave the door to the client’s room open slightly.
- C. Apply wrist restraints to prevent wandering.
- D. Provide a back rub at bedtime.
Correct Answer: B
Rationale: Back rub addresses agitation non-pharmacologically.
Which intervention should the nurse include in the plan of care for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink?
- A. Record the client’s daily weight.
- B. Maintain in high Fowler’s position.
- C. Keep mucous membranes moist.
- D. Report any change in urine color.
Correct Answer: C
Rationale: Moist membranes enhance comfort.
The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?
- A. Begin the collection the next day.
- B. Empty the sample into the 24-hour container.
- C. Observe the sample for sediment.
- D. Start collecting the specimen with the next void.
Correct Answer: D
Rationale: First void is discarded for accuracy.
The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
- A. Advise the UAP to hold the thermometer securely in place for a full three minutes.
- B. Use positive reinforcement to affirm that the procedure is being performed correctly.
- C. Demonstrate the correct technique for pulling the client’s auricle down and back.
- D. Remind the UAP to lubricate the thermometer before gently inserting it in the ear.
Correct Answer: B
Rationale: Up-and-back is correct for adults.
The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to ask the client about sexual activity. Which approach is best for the nurse to use?
- A. Begin with queries that are less sensitive in nature.
- B. Ask queries in a vague, non-specific format.
- C. Get the most difficult queries over with first.
- D. Share personal values to put the client at ease.
Correct Answer: A
Rationale: Less sensitive queries build rapport.