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 D
Explanation
Choice A rationale
While it’s true that many contraceptives can help prevent certain sexually transmitted infections (STIs), they are not 100% effective. Condoms, for instance, can reduce the risk of STIs that are spread through bodily fluids, such as gonorrhea and chlamydia. However, they are less effective at protecting against STIs that are transmitted through skin-to-skin contact, such as herpes and human papillomavirus (HPV)1.
Choice B rationale
Not all STIs are transmitted through sexual intercourse. Some STIs, such as herpes and HPV, can be spread through skin-to-skin contact. Others, like HIV and hepatitis B and C, can also be spread through sharing needles or from mother to child during childbirth.
Choice C rationale
Safe sex practices can significantly reduce, but not completely remove, the risk of STIs. These practices include using condoms correctly every time you have sex, getting tested regularly for STIs, and limiting the number of sexual partners.
Choice D rationale
Reinfections can indeed occur from having sex with untreated partners. This is particularly true for bacterial STIs like syphilis. If a person’s partner is not treated, the bacteria can remain in their body and they can pass the infection back to the person after they’ve been treated.
Correct Answer is ["18"]
Explanation
Step 1 is to calculate the infusion rate. The prescription is for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline.
So, the calculation would be (900 units ÷ 25,000 units) × 500 mL = 18 mL/hr.
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