An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Fall at home as the reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Currently prescribed medications.

Answer and Explanation

The Correct Answer is B

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

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Correct Answer is C

Explanation

Choice A reason: Right lower abdominal pain is not typically associated with Wernicke's syndrome and would likely indicate a different issue.

Choice B reason: Peripheral neuropathy can be a symptom of Wernicke's syndrome, but it is not as central to the condition as confusion, which is a hallmark sign.

Choice C reason: Confusion is a primary symptom of Wernicke's syndrome and should be used in planning the client's care, as it indicates acute encephalopathy and the need for immediate treatment with thiamine.

Choice D reason: Depression may be present in clients with Wernicke's syndrome, but it is not a primary assessment finding used to plan care for the acute stage of the condition.

A. White blood cell (WBC) count. B. Red blood cell (RBC) count. C. Serum potassium. D. Blood urea nitrogen (BUN). E. Sputum culture and sensitivity. F. Urinalysis.

Correct Answer is ["A","E"]

Explanation

Choice A reason: Monitoring the WBC count can help determine if the antibiotic is effectively treating an infection, as a decreasing count may indicate recovery.

Choice B reason: The RBC count is not typically affected by respiratory infections and is not a direct indicator of antibiotic effectiveness.

Choice C reason: Serum potassium levels are not directly related to the effectiveness of antibiotics for respiratory infections.

Choice D reason: BUN levels are more indicative of kidney function and are not used to evaluate antibiotic effectiveness for respiratory infections.

Choice E reason: A sputum culture and sensitivity test can identify the causative bacteria and determine if the antibiotic is effective.

Choice F reason: Urinalysis is not directly related to respiratory infections but can be part of a broader assessment of health.

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Naxlex Comprehensive Predictor Exams

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Correct Answer is C

Explanation

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the nurse monitor? Select all that apply.

Correct Answer is ["A","E"]

Explanation

A nurse is caring for a client who has been prescribed parenteral lidocaine. Before administering the medication, the nurse should review the medical record for which condition?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

For a client who has undergone surgery to repair a retinal detachment in the left eye, which intervention should the nurse implement during the postoperative period?

Patient Data Exhibits Which interventions are indicated to promote positive outcomes for the patient? Select all that apply.

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.