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 A

Explanation

Choice A reason: Whole milk and ice cream are high in fat, which can trigger the inflammation of the gallbladder (cholecystitis) and the formation of gallstones. The client should avoid foods that are high in fat, such as fried foods, cheese, butter, cream, and fatty meats.

Choice B reason: Citrus fruit and melon with a salt substitute are not a problem for a client with cholecystitis, unless they have other conditions that require dietary modifications, such as diabetes or kidney disease. The client should eat a balanced diet that includes fruits, vegetables, grains, and lean proteins.

Choice C reason: Pasta with herbal butter and no meat sauce is also acceptable for a client with cholecystitis, as long as the butter is used sparingly and the pasta is not cooked with oil or cheese. The client should limit the intake of refined carbohydrates, such as white bread, rice, and sugar, and choose whole grains instead.

Choice D reason: Canned vegetables with additional table salt are not recommended for a client with cholecystitis, because they are high in sodium, which can increase the risk of fluid retention and hypertension. The client should reduce the intake of salt and processed foods, such as canned soups, sauces, and snacks, and use herbs and spices to flavor the food.

A. Calculate gestation from last menstrual cycle. B. Continue with surgery as scheduled. C. Perform a bedside pregnancy test. D. Notify the surgical team to cancel the surgery.

Correct Answer is C

Explanation

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

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Naxlex Comprehensive Predictor Exams

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is A

Explanation

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Correct Answer is C

Explanation

An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

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?