NUR 2090 Exam 2 UPDATED ACTUAL Questions and
CORRECT Answers
documenting written communication and serves as a permanent record of patient
information and care
reporting verbal communication - when two or more people share information about
patient care - face to face or by telephone
any change of pt status is documented and reported
, subjective assessment normal pattern identification - risk identification - dysfunction identification
objective assessment measurable, observable - ex) vital signs
when documenting patient's current state document objectively - ex) patient appears angry, patient states...
verbal orders never accepted unless in emergency situations - nurse repeats back orders to
clarify
telephone orders accepted, but not really used currently
SBAR situation, background, assessment recommendation - ex)
SBAR situation clear and brief statement about the problem - include name, pt name, unit,
room number, vitals, concerns
SBAR background relevant clinical information related to the situation - include admission date
and dx, code status, meds, IV, labs, test results
SBAR assessment your patient assessment - include focused subjective and objective system
assessment
SBAR recommendation actions requested - examples include order change, referral, visit by provider
I PASS the BATON acronym introduction - patient - assessment - situation - safety concerns - background -
actions - timing - ownership - next
I PASS the BATON use comprehensive handoff report that may be used for transitions in care
huddles held at the beginning of a shift to highlight important issues that will need
attention
debriefing used after an event, especially an unexpected one, to explore what went well
and what could have been performed better
CUS concerned, uncomfortable, safety issue
isotonic cause no fluid shifts - cell maintains size - used to treat vascular expansion,
electrolyte replacement - ex) normal saline, lactated ringers
hypotonic move fluid into the cells and interstitial space - used to treat cellular
dehydration - ex) 0.45% NaCl
hypertonic draw fluid from the intracellular to the intravascular - used to treat intravascular
dehydration and sepsis - ex) 3% NaCl
signs of fluid overload dyspnea - shortness of breath - pulmonary edema (crackles) - orthopnea -
tachypnea - mental status change - HTN - bounding pulse - tachycardia -
jugular vein distention - peripheral edema - weight gain - decreased urine
output
CORRECT Answers
documenting written communication and serves as a permanent record of patient
information and care
reporting verbal communication - when two or more people share information about
patient care - face to face or by telephone
any change of pt status is documented and reported
, subjective assessment normal pattern identification - risk identification - dysfunction identification
objective assessment measurable, observable - ex) vital signs
when documenting patient's current state document objectively - ex) patient appears angry, patient states...
verbal orders never accepted unless in emergency situations - nurse repeats back orders to
clarify
telephone orders accepted, but not really used currently
SBAR situation, background, assessment recommendation - ex)
SBAR situation clear and brief statement about the problem - include name, pt name, unit,
room number, vitals, concerns
SBAR background relevant clinical information related to the situation - include admission date
and dx, code status, meds, IV, labs, test results
SBAR assessment your patient assessment - include focused subjective and objective system
assessment
SBAR recommendation actions requested - examples include order change, referral, visit by provider
I PASS the BATON acronym introduction - patient - assessment - situation - safety concerns - background -
actions - timing - ownership - next
I PASS the BATON use comprehensive handoff report that may be used for transitions in care
huddles held at the beginning of a shift to highlight important issues that will need
attention
debriefing used after an event, especially an unexpected one, to explore what went well
and what could have been performed better
CUS concerned, uncomfortable, safety issue
isotonic cause no fluid shifts - cell maintains size - used to treat vascular expansion,
electrolyte replacement - ex) normal saline, lactated ringers
hypotonic move fluid into the cells and interstitial space - used to treat cellular
dehydration - ex) 0.45% NaCl
hypertonic draw fluid from the intracellular to the intravascular - used to treat intravascular
dehydration and sepsis - ex) 3% NaCl
signs of fluid overload dyspnea - shortness of breath - pulmonary edema (crackles) - orthopnea -
tachypnea - mental status change - HTN - bounding pulse - tachycardia -
jugular vein distention - peripheral edema - weight gain - decreased urine
output
