A client has undergone a surgical procedure and develops a weak, rapid pulse.
Which intervention should the nurse recommend to provider during their SBAR communication?
Anticholinergic.
Urinary catheter placement.
Beta blocker.
Intravenous fluid bolus.
The Correct Answer is D
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should hold and notify the prescriber because hydrochlorothiazide is a diuretic that can lower the serum potassium level. The client already has a high serum potassium level of 5.2 mmol/L, which is above the normal range of 3.5 to 5.0 mmol/L.
Giving hydrochlorothiazide could worsen the client’s condition and cause hypokalemia.
Choice A is wrong because metoprolol is a beta-blocker that can lower the blood pressure and heart rate.
The client’s blood pressure and heart rate are not given, so there is no reason to hold metoprolol based on the information provided.
Choice C is wrong because enoxaparin is an anticoagulant that can prevent blood clots. The client has a low platelet count of 98,000/mm, which is below the normal range of 150,000 to 450,000/mm.
However, this does not contraindicate the use of enoxaparin, unless the client has signs of bleeding or bruising.
Choice D is wrong because atorvastatin is a statin that can lower the serum cholesterol
level. The client has a high serum cholesterol level of 250 mg/dL, which is above the desirable level of less than 200 mg/dL.
Giving atorvastatin could help reduce the client’s risk of cardiovascular complications.
Correct Answer is C
Explanation
The directive takes effect only if the client is incapable of personally making health care decisions. This statement demonstrates an understanding of health care proxy and care because it reflects the definition of a health care proxy as a person who can make health care decisions for the client only when the client is unable to communicate these themselves.
Choice A is wrong because the daughter does not have the authority to make all of the client’s health care decisions, only those that the client has not specified in advance or that are not covered by the living will.
Choice B is wrong because no extraordinary means, such as cardiopulmonary resuscitation, will be initiated only if the client has expressed this preference in a living will or a do-not-resuscitate order.
Choice D is wrong because the closest relative, such as the spouse, does not have to be consulted before the daughter in making health care decisions, unless the client has designated them as an alternate proxy.
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