A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?

Explain specific reason for urgent notification.

Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).

Preface the report by stating the client’s name and admitting diagnosis.

Communicate the pre-transfusion temperatures.

Answer and Explanation

The Correct Answer is C

Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.

Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

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Correct Answer is B

Explanation

Choice A reason: Wearing clothing to cover the radiation site is a correct action, as it can protect the skin from sun exposure, irritation, and infection. The clothing should be loose-fitting, soft, and made of natural fibers, such as cotton or linen. The clothing should also be changed daily and washed separately from other clothes.

Choice B reason: Washing the radiation site with antibacterial soap and water is an incorrect action, as it can dry out, damage, or inflame the skin. The skin in the radiation site is more sensitive and vulnerable to injury and infection. The client should use mild, unscented soap and water to gently cleanse the area once a day, and avoid rubbing or scrubbing the skin.

Choice C reason: Applying prescribed lotions to the radiation site is a correct action, as it can moisturize, soothe, and heal the skin. The client should use only the lotions that are recommended by the health care provider, and avoid any products that contain alcohol, perfume, or other irritants. The client should also apply the lotions at least one hour before or after the radiation treatment, and not during the treatment.

Choice D reason: Drying the area with patting motions after taking a shower is a correct action, as it can prevent friction and trauma to the skin. The client should use a soft, clean towel to gently pat the skin dry, and avoid rubbing or pulling the skin. The client should also avoid using hair dryers, heating pads, or ice packs on the radiation site.

A. Log roll the client and place adult disposable briefs beneath the client. B. Maintain traction while the client uses a urinal. C. Release the traction so the client can use a bedpan. D. Insert an indwelling urinary catheter preoperatively.

Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

Correct Answer is B

Explanation

A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

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A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

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