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 A
Explanation
The correct answer is A. The nurse should first implement the prescription of Cefazolin 1 gram intravenously every 6 hours.
This is because, on admission of a patient to the postanesthesia care unit (PACU) from surgery, the first priority is to assess the airway and breathing status. Administering Cefazolin, an antibiotic, helps prevent postoperative infections, which is crucial in the immediate postoperative period.
Correct Answer is B
Explanation
Choice A rationale
Exercise is an important part of managing type 2 diabetes as it helps regulate blood glucose levels. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also helps your body use insulin more efficiently. Therefore, the statement “Remember exercise will not affect blood glucose levels” is incorrect.
Choice B rationale
Moderate alcohol consumption is generally safe for most people with diabetes. A moderate amount of alcohol is up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Too much alcohol can cause blood sugar levels to drop too low and can also increase the risk of other health problems.
Choice C rationale
While it’s important to keep wounds clean and covered, using antibiotic ointment on every wound isn’t always necessary. Overuse of antibiotics can lead to antibiotic resistance. It’s best to consult with a healthcare provider for wound care advice.
Choice D rationale
Soaking feet in hot water can lead to burns or infections, especially if the person has neuropathy. It’s recommended to wash feet with warm — not hot — water and dry them gently, especially between the toes.
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