A patient 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, what information should the nurse provide first?
Client’s healthcare power of attorney.
Currently prescribed medications.
Fall at home as reason for admission.
Increasing confusion of the patient.
The Correct Answer is D
Choice A rationale
While the client’s healthcare power of attorney is important information, it 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
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 C 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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.
Choice B rationale
There is no specific “low bacteria diet” recommended for VRE infections20.
Choice C rationale
Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.
Choice D rationale
Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.
Choice E rationale
Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.
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