Nursing Elites

1. When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?

• A. SBAR
• B. SOAP
• C. PIE
• D. DAR

Correct answer: A

Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.

2. A cerebrovascular accident patient is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates no extraordinary life-saving measures. What action should the nurse take?

• A. Refer to the risk manager
• B. Notify the healthcare provider
• C. Discontinue the ventilator
• D. Review the medical record

Correct answer: B

Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.

3. The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rate
• C. Shortness of breath
• D. Headache

Correct answer: C

Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.

4. A nurse is providing care to a 17-year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?

• A. Abnormal breath sounds
• B. Cyanosis of the lips
• C. Increasing pulse rate
• D. Pulse oximeter reading of 92%

Correct answer: C

Rationale: An increasing pulse rate can be an early sign of poor oxygenation as the body tries to compensate. Abnormal breath sounds (choice A) can indicate respiratory issues, but they may not always be an early sign of poor oxygenation. Cyanosis of the lips (choice B) is a late sign of inadequate oxygenation. A pulse oximeter reading of 92% (choice D) indicates mild hypoxemia but may not be considered an early indication of poor oxygenation.

5. When evaluating care of an immobilized patient, which action will the nurse take?

• A. Focus on whether the interdisciplinary team is satisfied with the care.
• B. Compare the patient's actual outcomes with the outcomes in the care plan.
• C. Involve primarily the patient's family and health care team to determine goal achievement.
• D. Use objective data solely in determining whether interventions have been successful.

Correct answer: B

Rationale: When evaluating the care of an immobilized patient, the nurse should focus on assessing outcomes and response to nursing care. By comparing the patient's actual outcomes with the outcomes identified during planning, the nurse can determine the effectiveness of the interventions implemented. This process allows for a comprehensive evaluation of the care provided. Choice A is incorrect because the satisfaction of the interdisciplinary team does not directly reflect the patient's outcomes and response to care. Choice C is incorrect as it mainly focuses on the involvement of the patient's family and healthcare team, which may not provide a holistic evaluation of the patient's care. Choice D is incorrect as relying solely on objective data may lead to overlooking important subjective aspects of the patient's response and outcomes, which are also crucial in evaluating care effectively.

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