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:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg.

Correct Answer is D

Explanation

The correct answer isChoice D.

Choice A rationale:

Hypertension is not a contraindication for administering clonidine. In fact, clonidine is often used to treat hypertension.It works by decreasing the levels of certain chemicals in your blood, allowing your blood vessels to relax and your heart to beat more slowly and easily.

Choice B rationale:

An apical heart rate of 72 beats/minute is within the normal range (60-100 beats/minute) and would not be a contraindication for administering clonidine.Clonidine can lower heart rate, so it’s important to monitor heart rate, but a normal heart rate does not preclude its use.

Choice C rationale:

Muscle weakness is not a specific contraindication for the use of clonidine. While muscle weakness can be a side effect of many medications, it is not typically associated with clonidine.However, if a patient was experiencing severe or unusual muscle weakness, it would be important for the healthcare provider to evaluate this symptom.

Choice D rationale:

A blood pressure of 90/76 mm Hg could be a contraindication for the use of clonidine. Clonidine is a medication that is used to lower blood pressure, and if a patient’s blood pressure is already low, further lowering it could lead to symptoms such as dizziness, fainting, or even shock.Therefore, it would be important to monitor the patient’s blood pressure closely while they are taking this medication.

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Naxlex Comprehensive Predictor Exams

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

A nurse is reviewing the laboratory results of a client who is receiving intravenous unfractionated heparin. The nurse notes that the client’s activated partial thromboplastin time (aPTT) is 120 seconds. What are the appropriate nursing actions in this situation? Select all that apply.

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

A nurse is reviewing laboratory results for a client who has been taking amoxicillin-clavulanate (Augmentin) for a bacterial respiratory tract infection. Which of the following findings should alert the nurse to a possible adverse effect of this medication? (Select all that apply.).

A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?​​​​​​

A child who weighs 55 pounds receives a prescription for cefotaxime 150 mg/kg/day intravenously in divided doses every 6 hours. How many mg should the nurse administer each day?