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
“My medication will be given at the scheduled times to best manage my pain.” This statement demonstrates understanding of the pain management plan because it shows that the client knows the importance of preventing pain from becoming severe by taking medication regularly. Scheduled administration of analgesics is more effective than administering them on demand.
Choice A is wrong because it implies that the client will wait until the pain is severe before asking for medication, which can make it harder to control.
Choice C is wrong because it suggests that the client expects to receive inadequate pain relief due to their history of opioid abuse, which is not ethical or evidence-based.
Choice D is wrong because it indicates that the client believes they will be denied any narcotics for pain, which is also not ethical or
evidence-based. Clients with a history of opioid abuse can still receive opioids for acute pain, but they may need higher doses or more frequent administration to achieve adequate analgesia.
Normal ranges for vital signs are as follows: respiratory rate 12-20 breaths per minute, heart rate 60-100 beats per minute, blood pressure 120/80 mmHg, temperature 36.5-37.5°C (97.7- 99.5°F).
Correct Answer is B
Explanation
Select a 0.5 mL syringe, 30 gauge, 8 mm needle and inject at a 90-degree angle. This is because Humulin R is a clear and colorless solution that can be given by subcutaneous injection.
A 0.5 mL syringe can hold up to 50 units of insulin, which is enough for the prescribed dose of 7 units. A 30 gauge, 8 mm needle is suitable for thin patients with poor skin turgor. Injecting at a 90-degree angle ensures that the insulin reaches the subcutaneous tissue and not the muscle.
Choice A is wrong because a 31 gauge, 6 mm needle is too short and may not deliver the insulin into the subcutaneous tissue.
Choice C is wrong because pinching the skin is not necessary for thin patients with poor skin turgor.
Choice D is wrong because a 1.0 mL syringe is too large for the prescribed dose of 7 units and may cause dosing errors. A 28 gauge, 12.7 mm needle is too long and may inject the insulin into the muscle, which can affect its absorption and action.
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