Shift Change Report

A nurse prepares to contact a patient's physician about a change in the patient's condition. Put the following statements in the correct order using SBAR (Situation, Background, Assessment and Recommendation). 1. " The patient started complaining of nausea yesterday evening and has vomited several times during the night." 2. " She is a 53-year-old female who was admitted 2 days ago with pneumonia and was started on Levaquin at 5pm yesterday. She complains of a poor appetite. 3. " The patient reported feeling very nauseated after her dose of Levaquin an hour ago." 4. "Would you like to make a change in the antibiotics , or could we give her a nutritional supplement before her medications?"

2, 3, 4, 1?

A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is re-checked, and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a. Assessment b. Diagnosis c. Implementation d. Evaluation

a. Assessment

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18 to 44/min. b. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). c. Increased blood pressure from 112/68 to 120/72 mm Hg. d. Increased heart rate from 68 to 72/min.

a. Increased respiratory rate from 18 to 44/min. Abnormal vital signs should indicate to the nurse that the client could be developing a serious complication

Which situation will cause the nurse to intervene and follow up on the nursing assistive personnel's (NAP) behavior? a. The nursing assistive personnel is calling the older-adult patient "honey." b. The nursing assistive personnel is facing the older-adult patient when talking. c. The nursing assistive personnel cleans the older-adult patient's glasses gently. d. The nursing assistive personnel allows time for the older-adult patient to respond.

a. The nursing assistive personnel is calling the older-adult patient "honey." None or poor therapeutic communication will cause the nurse to intervene between a patient and a UAP. Using common or endearing terms such as honey is not appropriate in a health care setting.

Hand-off communication that occurs between the post anesthesia care unit (PACU) nurse and the nurse on the postoperative nursing unit need to be done when a patient returns to the nursing unit. Which are appropriate components of a safe and effective hand-off? (Select all that apply) a. Vital signs, type of anesthesia provided, blood loss, and level of consciousness b. Uninterrupted time to review the recent pertinent events and ask questions c. Verification of the patient using one identifier and the type of surgery performed d. Review of pertinent events occurring in the operating room (OR) while at the nurses station e. Location of the patient's family members

a. Vital signs, type of anesthesia provided, blood loss, and level of consciousness b. Uninterrupted time to review the recent pertinent events and ask questions e. Location of the patient's family members

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a. "I think you've had a hard day." b. "I feel uncomfortable hearing that statement." c. "I don't think you should say things like that. It is not right." d. "I have been checking on you regularly. How can you say that?"

b. "I feel uncomfortable hearing that statement."

A nurse is planning to use the SBAR communication tool when calling a provider. Which of the following statements should the nurse include in the B step? a. "The client should be seen by a neurologist." b. "The client was found unconscious on the floor in her home." c. "There are no provider's prescriptions available." d. "The client is disoriented. Pupils are slow to respond to light."

b. "The client was found unconscious on the floor in her home." This is part of the background information.

Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a. Sore throat b. Acute pain c. Sleep apnea d. Heart failure

b. Acute pain NANDA-I approved diagnosis are related to nursing actions, such as acute pain. The other choices are medical diagnosis which define the patient's condition.

After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a. To form a language that can be encoded only by nurses b. To distinguish the nurse's role from the physician's role c. To develop clinical judgment based on other's intuition d. To help nurses focus on the scope of medical practice

b. To distinguish the nurse's role from the physician's role

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. Decreased gastrointestinal motility b. Pain medication c. Abdominal distention d. Constipation

c. Abdominal distention Abdominal distention is a defining characteristic in the nursing care plan as related to constipation.

A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a. Glasgow results b. Intracranial pressure readings c. Code status d. Plan of care changes for upcoming shift

c. Code status The nurse should include in the background segment of SBAR the patient's code status.

A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What phrase is used to identify what the nurse is doing? a. Assigning clinical cues b. Defining characteristics c. Diagnostic reasoning d. Diagnostic labeling

c. Diagnostic reasoning

A patient was admitted 2 days ago with a diagnosis of pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Which piece of data will the nurse use for "B" when using SBAR? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed

c. History of angina The "B" in SBAR is background and history of angina is some background information for this patient

A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the following tasks should the nurse assign to the assistive personnel (AP)? a. Obtain initial vital signs. b. Determine if the client is in need of pain medication. c. Record the amount of urine in the catheter drainage bag. d. Instruct the client on the use of the incentive spirometer.

c. Record the amount of urine in the catheter drainage bag.

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? a. To promote autonomy b. To use common courtesy c. To establish trustworthiness d. To standardize communication

d. To standardize communication