D439: FOUNDATIONS QUESTIONS
AND ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+
The SBAR Communication Framework
Concept: SBAR is a standardized communication tool used to ensure critical
information is passed accurately between healthcare professionals. It stands for:
Situation: What is happening right now?
Background: What is the clinical context or history?
Assessment: What do I think the problem is?
Recommendation: What do I need from you? ✔✔
Escalation Tools: SBAR vs. CUS
Concept: Nurses use two primary structured tools to communicate a change in a
patient’s status. While SBAR provides the data and plan, the CUS tool is
specifically used to escalate concerns when a nurse feels a situation is becoming
unsafe.
Confirmed: "I am Concerned."
Uncomfortable: "I am Uncomfortable."
Safety: "This is a Safety issue." ✔✔
Patient Privacy Standards
Concept: Regardless of the communication tool being used (SBAR or CUS),
the nurse must strictly adhere to HIPAA and institutional policies. Always
ensure that sensitive patient data and identifiers remain confidential and are only
shared with the authorized care team in a secure environment.
SBAR EXAMPLE :
,Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400
mg PO to a patient 30 minutes ago for postsurgical pain. You return to the
patient's room to evaluate the effectiveness of the medication 30 minutes later.
The patient rates his pain as an 8 on a scale of 0-10. You use SBAR to contact
the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his
pain medication 30 minutes ago.
Background: The patient had a knee replacement and returned from the
postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5
mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain
medication he has taken since being admitted to the unit.
Assessment: His current medication order is not sufficiently managing the
patient's pain. He does not want to sit up or move because of the pain he is
experiencing.
Recommendation: It might be helpful to change the pain medication order for
the patient.
guided imagery -ANSWER ✔✔-mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs -ANSWER ✔✔-where (1) physiological needs are
PRIORITY then (2) safety and security, (3) love and belonging needs. (4) self
esteem needs, and FINALLY (5) self actualization needs
The nurse planning care for a client experiencing dystocia determines that the
priority is which action?
,1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth preparatory
classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's
Hierarchy of Needs theory to prioritize, remembering that physiological needs
come first. The nurse needs to have knowledge of the client's priority needs and
generate solutions. All the options are correct and would be implemented during
the care of a client with dystocia. Also note that the correct option is the only
one that addresses both the birthing parent and the fetus. Remember to use
Maslow's Hierarchy of Needs theory to help prioritize and generate solutions!
EHR system and limitations -ANSWER ✔✔-EHR AND EMR are different
from eachother
-A health care agency often relies on the nursing history model included in the
electronic health record (EHR) as the organizing framework for an assessment.
However, EHR frameworks are often medically driven. Frameworks developed
from nursing theories are more holistic and patient-centered, providing a more
comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer
system shuts down during data entry. The nurse should follow established
protocols and prepare to re-enter data as a late entry when the system is
operational. Also never attempt to reboot or fix the EMR system which may
prolong the complication.
It's also not recommended to print EMR from a backup server without proper
authorization and ensuring data privacy and security.
, -patient outcome data; and use clinical decision support systems. The electronic
health record (EHR) is an efficient method for documenting and managing
patient health care information (see Chapter 26.) Computerized
physician/provider order entry (CPOE), allowing health care providers to
directly enter medical orders, is a critical patient safety initiative especially in
the area of medication ordering and administration
-Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to
keep all health care providers and patients informed
Hand Hygeine -ANSWER ✔✔-hand washing does not kill microorganisms but
reduces the amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub,
surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
Dosage Calculation (ml, tbsp->ml) -ANSWER ✔✔
VITAL SIGNS -ANSWER ✔✔-what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? -ANSWER ✔✔TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left
foot together, left crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
AND ANSWERS WITH COMPLETE
SOLUTIONS 100% CORRECT RATED
A+
The SBAR Communication Framework
Concept: SBAR is a standardized communication tool used to ensure critical
information is passed accurately between healthcare professionals. It stands for:
Situation: What is happening right now?
Background: What is the clinical context or history?
Assessment: What do I think the problem is?
Recommendation: What do I need from you? ✔✔
Escalation Tools: SBAR vs. CUS
Concept: Nurses use two primary structured tools to communicate a change in a
patient’s status. While SBAR provides the data and plan, the CUS tool is
specifically used to escalate concerns when a nurse feels a situation is becoming
unsafe.
Confirmed: "I am Concerned."
Uncomfortable: "I am Uncomfortable."
Safety: "This is a Safety issue." ✔✔
Patient Privacy Standards
Concept: Regardless of the communication tool being used (SBAR or CUS),
the nurse must strictly adhere to HIPAA and institutional policies. Always
ensure that sensitive patient data and identifiers remain confidential and are only
shared with the authorized care team in a secure environment.
SBAR EXAMPLE :
,Case Study: You administered 1 tablet of oxycodone HCl 5 mg/ibuprofen 400
mg PO to a patient 30 minutes ago for postsurgical pain. You return to the
patient's room to evaluate the effectiveness of the medication 30 minutes later.
The patient rates his pain as an 8 on a scale of 0-10. You use SBAR to contact
the patient's health care provider.
Situation: The patient is rating his pain as an 8 on a scale of 0-10. He had his
pain medication 30 minutes ago.
Background: The patient had a knee replacement and returned from the
postanesthesia care unit 6 hours ago. He has 1 tablet of oxycodone HCl 5
mg/ibuprofen 400 mg PO ordered every 6 hours. This is the first pain
medication he has taken since being admitted to the unit.
Assessment: His current medication order is not sufficiently managing the
patient's pain. He does not want to sit up or move because of the pain he is
experiencing.
Recommendation: It might be helpful to change the pain medication order for
the patient.
guided imagery -ANSWER ✔✔-mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs -ANSWER ✔✔-where (1) physiological needs are
PRIORITY then (2) safety and security, (3) love and belonging needs. (4) self
esteem needs, and FINALLY (5) self actualization needs
The nurse planning care for a client experiencing dystocia determines that the
priority is which action?
,1. Position changes and providing comfort measures
2. Explanations to the client about what is happening
3. Monitoring for changes in the condition of the birthing parent and fetus
4. Encouraging the use of breathing techniques learned in childbirth preparatory
classes
Answer: 3
Test-Taking Strategy: Note the strategic word, priority, and use Maslow's
Hierarchy of Needs theory to prioritize, remembering that physiological needs
come first. The nurse needs to have knowledge of the client's priority needs and
generate solutions. All the options are correct and would be implemented during
the care of a client with dystocia. Also note that the correct option is the only
one that addresses both the birthing parent and the fetus. Remember to use
Maslow's Hierarchy of Needs theory to help prioritize and generate solutions!
EHR system and limitations -ANSWER ✔✔-EHR AND EMR are different
from eachother
-A health care agency often relies on the nursing history model included in the
electronic health record (EHR) as the organizing framework for an assessment.
However, EHR frameworks are often medically driven. Frameworks developed
from nursing theories are more holistic and patient-centered, providing a more
comprehensive patient review.
-When it comes to the EMR freezing it's best to notify IT or when the computer
system shuts down during data entry. The nurse should follow established
protocols and prepare to re-enter data as a late entry when the system is
operational. Also never attempt to reboot or fix the EMR system which may
prolong the complication.
It's also not recommended to print EMR from a backup server without proper
authorization and ensuring data privacy and security.
, -patient outcome data; and use clinical decision support systems. The electronic
health record (EHR) is an efficient method for documenting and managing
patient health care information (see Chapter 26.) Computerized
physician/provider order entry (CPOE), allowing health care providers to
directly enter medical orders, is a critical patient safety initiative especially in
the area of medication ordering and administration
-Change-of-shift, hand-off reporting, and hourly bedside rounds are ways to
keep all health care providers and patients informed
Hand Hygeine -ANSWER ✔✔-hand washing does not kill microorganisms but
reduces the amount of them present
-four techniques: hand washing, antiseptic hand wash, antiseptic hand rub,
surgical hand antisepsis
-4 elements of hand washing: water, friction, soap , and time
Dosage Calculation (ml, tbsp->ml) -ANSWER ✔✔
VITAL SIGNS -ANSWER ✔✔-what to do if reassessment is needed
-know the pt usual range of vital signs (baseline)
-assess respiratory
Factors affecting vital signs of older adults:
MOBILITY: How do you use crutches? -ANSWER ✔✔TYPES OF GAITS:
-2-point: 2 points (crutch or foot) on the ground: pt moves right crutch and left
foot together, left crutch and right foot together
-4 point gait:
-3 point gait: moving both crutches and the injured leg at the same time
