A nurse is caring for a client who is postoperative.
Which of the following should the nurse request as a recommendation in an SBAR report to the provider? (Select All that Apply.)
Oxygen 2 to 4 L/min via nasal cannula
Medication for elevated temperature
Insertion of NG tube for decompression
Evaluation of surgical wound drain
Insertion of urinary catheter
Correct Answer : B,D
A: The client's SpO2 is 95%, which is within an acceptable range, so oxygen therapy is not required at this time.
B: The client has a mild fever (37.8°C), and acetaminophen is indicated to help manage fever and improve comfort.
C: There is no indication of bowel obstruction or complications that would require an NG tube for decompression at this time.
D: The wound drain has had no output in 8 hours, which could indicate a blockage or other issue, warranting evaluation by the provider.
E: There is no indication of urinary retention or issues that would necessitate the insertion of a urinary catheter at this time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Decreased blood pressure and a rapid pulse are signs of hemodynamic instability, but they do not specifically indicate the need for phenytoin.
B. Pain and tingling at the access site are not related to seizures.
C. Headache and restlessness can be early signs of seizures or seizure activity, and phenytoin is indicated for seizure prevention and treatment.
D. Muscle cramps and chest heaviness are common symptoms of dialysis but are not indications for phenytoin.
Correct Answer is B
Explanation
A: Dairy is high in phosphorus and potassium—restriction is correct.
B: Clients with chronic kidney disease should consume low to moderate amounts of protein to avoid excess nitrogenous waste buildup. High-protein intake increases renal workload.
C: Protein restriction helps protect renal function.
D: Clients should avoid high-potassium foods like bananas, potatoes, and oranges.
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