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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: We need to find out how many mL contain 10 mg of loratadine. Since 5 mg of loratadine is in 5 mL, we can set up a proportion to find out how many mL contain 10 mg.
So, 5 mg is to 5 mL as 10 mg is to X mL.
This gives us the equation: (5 mg ÷ 5 mL) = (10 mg ÷ X mL)
Step 2: Solving for X gives us X = (10 mg × 5 mL) ÷ 5 mg
Step 3: Simplifying gives us X = 10 mL
So, the client needs to take 10 mL of the loratadine suspension to get a dose of 10 mg.
Now, we need to convert this volume in mL to teaspoons, using the conversion factor you provided (1 teaspoon = 5 mL).
Step 4: We set up the conversion as follows: 10 mL × (1 tsp ÷ 5 mL)
Step 5: Simplifying gives us 2 tsp
So, the nurse should instruct the client to take 2 teaspoons of the loratadine suspension.
Correct Answer is B
Explanation
Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.
Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.
Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.
Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.
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