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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Administering two medications to the same client at the wrong time is a serious error, but it may not be the most critical issue for reporting to the Peer Review Committee (PRC).
Choice B rationale: Changing work assignments without prior approval may be a workplace issue but does not directly endanger patient safety, so it may not be the primary focus of the PRC.
Choice C rationale: Serving a diet tray to a client who is NPO is a serious error that can lead to complications and warrants reporting to the PRC.
Choice D rationale: Documenting data in the clinical record before assessing the client's condition may indicate a documentation error, but it does not pose an immediate risk to the patient's well-being.
Correct Answer is A
Explanation
Choice A rationale: Conducting a closer examination of staff nurses' distribution of pain medication is the first step to identify any issues or patterns contributing to the higher than-usual administration of narcotic pain medications.
Choice B rationale: Holding a mandatory staff meeting may be necessary, but a focused examination should precede broader discussions.
Choice C rationale: Questioning clients about the effectiveness of pain medication is an important aspect of the investigation but should follow a thorough examination of medication distribution.
Choice D rationale: Discussing with the healthcare provider about changing client analgesia may be considered later based on the findings of the examination.
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