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 A
Explanation
Cataracts are a condition where the lens of the eye becomes opaque, causing impaired vision. Blurred or cloudy vision is a common symptom of cataracts.
Some possible explanations for the other choices are:
Choice B. Burning sensation in the eye. This is not a typical symptom of cataracts, but it could indicate an infection, allergy, or dry eye syndrome.
Choice C. Inability to produce tears. This is also not a typical symptom of cataracts, but it could indicate a problem with the lacrimal glands or ducts that produce and drain tears.
Choice D. A swollen lacrimal gland. This is not a symptom of cataracts, but it could indicate an inflammation or infection of the lacrimal gland, which is located near the upper eyelid.
Normal ranges for visual acuity are 20/20 for normal vision and 20/40 for mild impairment. Visual acuity can be measured using a Snellen chart or other methods.
Correct Answer is ["A","C"]
Explanation
Choice A is correct because using a soft toothbrush can decrease the risk of bleeding from the gums, which is a common site of bleeding for people with hemophilia.
Choice C is correct because reporting excessive bleeding to the provider and using precautions to protect the head and joints are important aspects of home care for hemophilia.
Choice B is wrong because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and increase bleeding tendency. People with hemophilia should avoid NSAIDs and use acetaminophen instead for pain relief.
Choice D is wrong because clotting factor treatments are not only needed when a bleed occurs but also as a preventive measure to reduce the frequency and severity of bleeding episodes. People with severe hemophilia need regular clotting factor replacement therapy for the rest of their lives.
Choice E is wrong because warm, painful joints are signs of joint bleeding, which is a serious complication of hemophilia that can lead to permanent joint damage.
People with hemophilia should not apply heat to their joints, but rather use ice packs, compression, elevation and rest to reduce swelling and pain. They should also seek medical attention and receive clotting factor replacement therapy as soon as possible.
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