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A nurse is using SBAR communication technique during a crisis. Which nursing intervention reflects "R"
step of this technique?
A. recording the reaction of the patient to the crisis
B. reassessing the pt after medical intervention
C. recommending a potential action to manage the crisis
D. reporting the situation to the primary health-care provider - correct answer ✔C
Which activity is the nurse engaged in when identifying a nursing diagnosis?
A. discovering causes of disease
B. documenting desired expected outcomes
C. planning care to meet nursing needs of a pt
D. planning care to meet nursing needs of a pt - correct answer ✔D
The nurse is caring for a pt with a healing stage III pressure ulcer. Upon entering the room the nurse
notices an odor and observes a purulent discharge. Along with increased redness at the wound site.
What is the next best step for the nurse?
A. notify the charge nurse about the change in status and the potential for infection
B. notify the PCP by utilizing SBAR
C. complete the head to toe assessment and include current treatment, vitals, and lab results
D. notify the wound care nurse about the change in status and the potential for infection - correct
answer ✔C
Which nursing action is an example of the assessment step of the nursing process?
A. administering pain meds for a headache
, B. taking a pt's BP after ambulating
C. communicating info obtained from an interview
D. determining if a pt tolerated the change from a soft to a regular diet - correct answer ✔C
The nurse is preparing to administer meds to 2 pts w/ the same last name. After the administration the
nurse realizes she did not check the identification of the pt before administering meds. Which of the
following actions should the nurse complete first?
A. return to the room and assess the pt
B. administer the antidote to the pt immediately
C. alert the charge nurse that a med error has occurred
D. complete proper documentation of the medication error in the pts chart - correct answer ✔A
The nurse is assessing a pt. What info collected by the nurse reflects subjective information?
A. clammy skin
B. agitated behavior
C. numbness of the feet
D coughing after a deep breath - correct answer ✔C
The nurse is assessing a pt. What clinical manifestation experienced by the pt. is an example of objective
information?
A. edema
B. heartburn
C. chest pain
D. lightheadedness - correct answer ✔A