A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
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.

Fall at home as reason for admission.

Currently prescribed medications.

Increasing confusion of the client.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.

Choice B rationale:

While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.

Choice C rationale:

The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.

Choice D rationale:

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.

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Correct Answer is C

Explanation

Choice A rationale:

Ketonuria is not a common complication of diabetes insipidus. Ketonuria is associated with diabetes mellitus, a different condition that results in the accumulation of ketones in the urine due to insufficient insulin.

Choice B rationale:

Peripheral edema is also an unlikely complication of diabetes insipidus. Diabetes insipidus is characterized by excessive thirst and urination, not fluid retention or peripheral edema.

A. Encourage the client to continue with the scheduled surgery. B. Document that the client has expressed concerns about the surgery. C. Notify the charge nurse of the client's concerns about surgery. D. Remind the client that the consent has already been obtained.

Correct Answer is C

Explanation

When a preoperative client expresses fear and uncertainty about undergoing surgery, the priority action for the practical nurse (PN) is to notify the charge nurse of the client's concerns. This is important because the charge nurse can coordinate appropriate interventions and support for the client, ensuring their emotional well-being and addressing their fears.

Let's evaluate the other options:

a) Encourage the client to continue with the scheduled surgery.
While it is important to provide support and reassurance to the client, simply encouraging them to continue with the scheduled surgery may not adequately address their specific concerns and fears. The charge nurse and the healthcare team should be involved to provide the necessary support and information to help alleviate the client's anxiety.

b) Document that the client has expressed concerns about the surgery.
Documenting the client's concerns is important for accurate record-keeping and continuity of care. However, it should not be the only action taken. Notifying the charge nurse is crucial to ensure appropriate follow-up and support for the client.

d) Remind the client that the consent has already been obtained.
Reminding the client that they have already signed the informed consent may not eﬀectively address their fears and concerns. Reassurance and support should be provided, and involving the charge nurse and healthcare team is essential to address the client's emotional well-being.

In summary, when a preoperative client confides in the practical nurse (PN) about being frightened and unsure about undergoing surgery, the priority action is to notify the charge nurse of the client's concerns. This allows for appropriate interventions, support, and coordination of care to address the client's fears, ensure their emotional well-being, and provide necessary information about the surgical procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Correct Answer is C

Explanation

A male preoperative client who has already signed the informed consent for a surgical procedure confides in the practical nurse (PN) that he is really frightened and unsure about undergoing the surgery. Which priority action should the PN take?

Correct Answer is C

Explanation

A client who is reaching saturation with medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN is a priority?

After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior?

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using the thermometer. Which action should the PN take first?

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?