A client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family presents the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Client's healthcare power of attorney.

Increasing confusion of the client.

Currently prescribed medications.

Fall at home as reason for admission.

Answer and Explanation

The Correct Answer is B

Choice A rationale: The assessment is the client's signed power of attorney and a home medication list, which are important documents that indicate the client's wishes and potential drug interactions. While the client's healthcare power of attorney is important information, the reason for admission should be provided first to give context to the situation.

Choice B rationale: The nurse should start by presenting the immediate situation or concern, which is the client's increasing confusion which needs immediate attention. Choice C rationale: The recommendation is the nurse's suggestion for further diagnostic tests, interventions, or referrals based on the situation, background, and assessment. The currently prescribed medications are relevant, but the primary reason for admission should be communicated first to establish the context of the client's condition. Choice D rationale: The background is the fall at home as the reason for admission, which explains the possible cause of the confusion and the loss of consciousness. This comes after the situation which is the increasing confusion.

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Correct Answer is D

Explanation

Choice A rationale: Directing the UAP to delay weighing the client might not address the underlying issue. Understanding the client's refusal is essential for appropriate interventions.

Choice B rationale: Documenting that the client refused daily weights is important for documentation purposes, but it doesn't address the issue or provide information on the client's fluid status.

Choice C rationale: Instructing the UAP to weigh the client using a bed scale is a good option, but understanding the client's concerns or reasons for refusal is important for effective communication and addressing potential issues.

Choice D rationale: Asking the client why he does not want to be weighed is essential for understanding and addressing the client's concerns. It allows the nurse to provide education, reassurance, or alternative solutions to ensure the client's cooperation with the prescribed care plan.

A. Two hours after receiving morphine for acute pain, a client's vital signs are BP 112/60 mm Hg, pulse 88 beats/minute, and respirations 14 breaths/minute. B. One hour after receiving hydromorphone prescribed for every 4 hours PRN use, a client reports severe pain. C. The fentanyl transdermal patch for a client with chronic cancer pain needs to be replaced. D. After ambulating, a postoperative client grimaces and reports incisional pain at a "9" on a ten-point scale.

Correct Answer is B

Explanation

Choice A rationale: Vital signs within the normal range two hours after receiving morphine do not indicate an immediate need for intervention by a registered nurse. Choice B rationale: A client reporting severe pain one hour after receiving hydromorphone requires assessment and intervention by a registered nurse to determine the cause of the pain and implement appropriate measures. Hydromorphone is a potent opioid analgesic that can cause serious side effects such as respiratory depression, sedation, hypotension, and constipation. A registered nurse has the knowledge and skills to monitor these effects and intervene if necessary.

Choice C rationale: Changing a fentanyl transdermal patch is a routine procedure and can be safely performed by a practical nurse.

Choice D rationale: A postoperative client reporting incisional pain requires assessment, but the pain level alone does not indica

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Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports to the nurse that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the nurse implement?

Correct Answer is D

Explanation

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

Correct Answer is B

Explanation

Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?

The nurse receives change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?