WGU D439: FOUNDATIONS ACCURATE AND
VERIFIED 2026
SBAR Format - Answers - -model for effective communication identifying Situation,
Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to communicate a
patients change in condition: CUS tool (Concerned, Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
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 - Answers - -mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs - Answers - -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 - Answers - -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 - Answers - -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) - Answers -
VITAL SIGNS - Answers - -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? - Answers - 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
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches on
the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger
Widths Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not
Axilla), With Elbows Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae and arm
piece has to be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
Wound Care and skin integrity (ch 48) - Answers - -levels of intention
-wound care
-wound stages
-what to do if device is causing irritation on pts skin
Stages of wounds: - Answers - 1.) unblanchable/surface: intact skin, may appear
differently in darker skin. redness, hardness and heat present.
2.) partial skin: possible serum-filled blister. has exposed dermis. Adipose isnt shown,
fat and deeper tissues arent shown.
*looks like a hand when its touched something hot and turned into a blister, red and
peely
3.) deeper tissue: loss of skin, adipose tissue is shown inside of the ulcer, slough or
eschar is visible, no bone and tissue. Fascia and muscle not shown
4.) bone and tendon: fascia is shown, can touch bone, ligaments and tendons in the
ulcer, tunneling
5.) unstageable: full thickness in which the stage of the ulcer cant be seen because of
the slough and eschar
Blister Treatment - Answers - Blisters are stage 2 pressure ulcers
-skin blisters or forms an open sore
-partial thickness with exposed dermis
-the wound bed is viable, pink or red, and moist ma be a serum filled
Nurse Actions:
VERIFIED 2026
SBAR Format - Answers - -model for effective communication identifying Situation,
Background, Assessment, and Recommendation
-there are two types of ways that communication tools are used to communicate a
patients change in condition: CUS tool (Concerned, Uncomfortable, Safety) and SBAR
-note to always maintain pt privacy and confidentiality
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 - Answers - -mind/body intervention
-Concentrating on an image or series of images to treat pathological conditions
Maslow's Hierarchy of Needs - Answers - -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 - Answers - -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 - Answers - -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) - Answers -
VITAL SIGNS - Answers - -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? - Answers - 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
-weight is on both hands
support weight at the hand grips, with elbow flexed at 30 degrees, position crutches on
the unaffected side when sitting or raising from the chair
-How to use crutches: Do Not Adjust Crutch Settings After Fitting (Should be 3 Finger
Widths Between Axilla and Top of Crutch) Support Body Weight on Hand Grips (Not
Axilla), With Elbows Flexed or bent at 30 Degrees
-an accurate measurement is important and the distance between the axillae and arm
piece has to be 2-3 finger widths in the axilla space and the arm bars
-all weight should be on the hand grips
-when ambulating pt, stand on their affected (weak) side
-never rest armpit on the axillary bars
Wound Care and skin integrity (ch 48) - Answers - -levels of intention
-wound care
-wound stages
-what to do if device is causing irritation on pts skin
Stages of wounds: - Answers - 1.) unblanchable/surface: intact skin, may appear
differently in darker skin. redness, hardness and heat present.
2.) partial skin: possible serum-filled blister. has exposed dermis. Adipose isnt shown,
fat and deeper tissues arent shown.
*looks like a hand when its touched something hot and turned into a blister, red and
peely
3.) deeper tissue: loss of skin, adipose tissue is shown inside of the ulcer, slough or
eschar is visible, no bone and tissue. Fascia and muscle not shown
4.) bone and tendon: fascia is shown, can touch bone, ligaments and tendons in the
ulcer, tunneling
5.) unstageable: full thickness in which the stage of the ulcer cant be seen because of
the slough and eschar
Blister Treatment - Answers - Blisters are stage 2 pressure ulcers
-skin blisters or forms an open sore
-partial thickness with exposed dermis
-the wound bed is viable, pink or red, and moist ma be a serum filled
Nurse Actions:
