Question

The nurse is preparing to call report to the receiving unit on a client in their care. They are preparing to use the SBAR report method. The nurse is aware the acronym SBAR includes the following components: (Select all that apply)

Answer 1

Correct Answers:

Situation
Background
Assessment
Recommendation

Rationale :

🗣️Situation identifies the immediate reason for the communication and gives the receiving nurse the current client concern.

📋Background provides important clinical history, diagnosis, treatments, and relevant events leading to the current condition.

🩺Assessment summarizes the nurse’s current clinical findings and interpretation of the client’s status.

✅Recommendation communicates the next needed action, request, or plan to promote safe continuity of care.

📌Core Message

SBAR means Situation, Background, Assessment, and Recommendation for clear and safe nursing communication.

Answer 2

Correct Answers:

"I'm pretty sure the client's spouse is angry that drunk driving was the cause of that femur fracture."
"I boiled my clothes after caring for the new client with scabies."
"I will send you a private message about that sad client with terminal cancer."

Rationale :

🔒Client confidentiality is violated when a post includes enough clinical or personal details that could identify a client.

🚗Drunk driving, spouse reaction, and femur fracture create a specific situation that risks exposing protected client information.

🧴Mentioning a new client with scabies reveals a specific client condition and care situation within the facility.

📩Sharing details about a terminal cancer client through a private message still violates confidentiality because protected information must not be discussed on social media.

📌Core Message

Client confidentiality is violated when social media posts reveal identifiable health information, diagnoses, injuries, or private care details.

Answer 3

Correct Answers:

Improves access to information
Reduces the risk of medication administration errors

Rationale :

💻Electronic medication administration records improve access to current medication information at the point of care.

🧾eMAR systems help nurses review scheduled medications, administration times, allergies, and documentation more efficiently.

🛡️Medication safety improves because electronic records reduce missed doses, duplicate entries, and documentation errors.

💁‍♂️Error reduction is a major benefit because electronic systems support safer medication administration and clearer communication.

📌Core Message

Electronic medication administration records improve access to medication information and reduce medication error risk.

Answer 4

Correct Answers:

Administration of oral medication
Assistance with range-of-motion exercises

Rationale :

🚶Assistance with ambulation is appropriate for unlicensed assistive personnel when the client is stable and the task is routine.

🦵Range-of-motion exercises may be assigned when they are part of basic care and do not require nursing judgment.

👥Delegation to unlicensed assistive personnel should involve predictable tasks with clear instructions and expected outcomes.

👉Basic mobility support is within the role of unlicensed assistive personnel when the nurse remains responsible for assessment and evaluation.

📌Core Message

Unlicensed assistive personnel may assist with routine ambulation and range-of-motion exercises for stable clients.

Answer 5

Correct Answers:

A 17-year-old female client who presents with a positive pregnancy test and vaginal bleeding
A 60-year-old client with.hypertension, diabetes, and chest pain who is seen in an urgent care setting
A 40-year-old client with peritonitis admitted to the ICU with impending respiratory failure requiring urgent intubation and mechanical ventilation
An 89-year-old client with multi-infarct dementia and pneumonia who is disoriented to place and time

Rationale :

⚖️Client rights include being informed about care and participating in decisions whenever the client can reasonably understand the healthcare information.

🤰Pregnancy-related care gives the adolescent client the right to receive information and participate in decisions about pregnancy complications.

😣Chest pain with chronic conditions requires clear explanation because the client has the right to understand the diagnostic and treatment plan.

🚑Emergency care still requires communication with the client when possible, even when urgent intervention such as intubation is needed.

🧠Cognitive impairment does not remove the client’s right to receive information in a way that supports remaining decision-making ability.

📌Core Message

Client rights include being informed and participating in care decisions whenever possible, even during pregnancy, urgent illness, or partial cognitive impairment.

Answer 6

Correct Answers:

Intravenous cefazolin given to a client with a history of anaphylaxis to penicillin
Pravastatin given to a woman at 10 weeks' gestation

Rationale :

💊Cefazolin should be reported when given to a client with a history of anaphylaxis to penicillin because of the potential for serious allergic reaction.

⚠️Anaphylaxis history represents a high-risk allergy concern that requires careful medication review before giving related antibiotics.

🤰Pravastatin should be reported because statins are generally avoided during pregnancy due to fetal safety concerns.

✅Medication practice errors must be reported when they involve a serious allergy risk or a medication that is unsafe in pregnancy.

📌Core Message

Medication errors include giving a high-risk drug despite anaphylaxis history or administering a contraindicated medication during pregnancy.

Answer 7

Correct Order:

Order : 1 : No answer text available
Order : 2 : No answer text available
Order : 3 : No answer text available
Order : 4 : No answer text available

Rationale :

👶Vital signs and weight are priority because they provide baseline data for the severity of dehydration.

💧IV fluid therapy is urgent because lethargy, sunken fontanel, and dry mouth indicate significant fluid volume deficit.

🚽Urine collection helps monitor hydration status and kidney response after fluid resuscitation begins.

🧪Blood tests help evaluate electrolyte imbalance, but immediate stabilization of circulation and hydration remains the priority.

📌Core Message

A dehydrated infant requires rapid vital signs, weight assessment, IV fluid replacement, urine monitoring, and laboratory evaluation.

Answer 8

Correct Answers:

Enforcing the State Practice Act for nurses
Granting nursing licenses and overseeing licensing exams
Disciplining nurses who have practiced in an unsafe manner

Rationale :

⚖️State boards of nursing enforce the Nurse Practice Act to protect the public and regulate nursing practice.

💁‍♂️Licensure authority belongs to the state board, including granting licenses and overseeing requirements for nursing practice.

📋Licensing exams are connected to board approval because safe entry into practice requires meeting professional standards.

🚨Disciplinary action is a board function when nurses practice unsafely or violate professional regulations.

📌Core Message

The state board of nursing protects the public by enforcing the Nurse Practice Act, licensing nurses, and disciplining unsafe practice.

Answer 9

Correct Answers:

Having a high self esteem and taking risks
Standing erect
Respecting the rights of others

Rationale :

🗣️Assertive communication involves expressing thoughts clearly while maintaining respect for the rights of others.

💪High self-esteem supports assertiveness because the nurse can communicate needs and concerns with confidence.

🧍Standing erect reflects confident body language and supports a clear professional presence.

🤝Respecting the rights of others is essential because assertiveness balances self-expression with mutual respect.

📌Core Message

Assertive communication combines confidence, respectful body language, and protection of both personal and client rights.

Answer 10

Correct Answers:

Battery
False imprisonment

Rationale :

⚖️Battery occurs when there is intentional physical contact or restraint without proper legal authorization or consent.

🚪False imprisonment occurs when a client is unlawfully restricted from leaving a healthcare setting.

🛑Restraints require proper clinical justification and a valid prescription except in emergency safety situations handled by policy.

👉Intentional tort liability can occur when the nurse physically restrains a client and prevents movement without proper legal basis.

📌Core Message

Improper use of restraints may create liability for battery and false imprisonment when client freedom is unlawfully restricted.

1 :
The nurse is preparing to call report to the receiving unit on a client in their care. They are preparing to use the SBAR report method. The nurse is aware the acronym SBAR includes the following components: (Select all that apply)

2 :
Several nurses who work at the same hospital are communicating on social media. Which of the following posts by one of the nurses violates client confidentiality? (Select all that apply.)

3 :
Which of the following is a benefit associated with electronic medication administration records? (Select all that apply.)

4 :
Which of the following tasks can a nursing supervisor assign to unlicensed assistive personnel on a unit? (Select all that apply.)

5 :
A nurse working in a busy urban emergency department understands that the following clients have a right to be informed about all aspects of their care and to participate in making decisions about that care? (select all that apply)

6 :
A nurse is reviewing the medication administration record. Which of the following items should be reported as practice errors? Select all that apply.

Available Items

Arrange Your Answers

8 :
Which of the following are the roles of a state board of nursing? (Select all that apply.)

9 :
Which of the following examples demonstrates an assertive communication style by the nurse? (Select all that apply)

10 :
A nurse applies restraints without a prescription to a client who threatens to leave against medical advice. For which of the following intentional torts may the nurse incur liability as a result (select all that apply)?

1 : The nurse is preparing to call report to the receiving unit on a client in their care. They are preparing to use the SBAR report method. The nurse is aware the acronym SBAR includes the following components: (Select all that apply)

2 : Several nurses who work at the same hospital are communicating on social media. Which of the following posts by one of the nurses violates client confidentiality? (Select all that apply.)

3 : Which of the following is a benefit associated with electronic medication administration records? (Select all that apply.)

4 : Which of the following tasks can a nursing supervisor assign to unlicensed assistive personnel on a unit? (Select all that apply.)

5 : A nurse working in a busy urban emergency department understands that the following clients have a right to be informed about all aspects of their care and to participate in making decisions about that care? (select all that apply)

6 : A nurse is reviewing the medication administration record. Which of the following items should be reported as practice errors? Select all that apply.

Available Items

Arrange Your Answers

8 : Which of the following are the roles of a state board of nursing? (Select all that apply.)

9 : Which of the following examples demonstrates an assertive communication style by the nurse? (Select all that apply)

10 : A nurse applies restraints without a prescription to a client who threatens to leave against medical advice. For which of the following intentional torts may the nurse incur liability as a result (select all that apply)?

1 :
The nurse is preparing to call report to the receiving unit on a client in their care. They are preparing to use the SBAR report method. The nurse is aware the acronym SBAR includes the following components: (Select all that apply)

2 :
Several nurses who work at the same hospital are communicating on social media. Which of the following posts by one of the nurses violates client confidentiality? (Select all that apply.)

3 :
Which of the following is a benefit associated with electronic medication administration records? (Select all that apply.)

4 :
Which of the following tasks can a nursing supervisor assign to unlicensed assistive personnel on a unit? (Select all that apply.)

5 :
A nurse working in a busy urban emergency department understands that the following clients have a right to be informed about all aspects of their care and to participate in making decisions about that care? (select all that apply)

6 :
A nurse is reviewing the medication administration record. Which of the following items should be reported as practice errors? Select all that apply.

8 :
Which of the following are the roles of a state board of nursing? (Select all that apply.)

9 :
Which of the following examples demonstrates an assertive communication style by the nurse? (Select all that apply)

10 :
A nurse applies restraints without a prescription to a client who threatens to leave against medical advice. For which of the following intentional torts may the nurse incur liability as a result (select all that apply)?