An older client admitted for observation following a fall while getting out of the bathtub becomes increasingly confused. The family arrives with the home medication list and the client’s healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which 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 client.

Answer and Explanation

The Correct Answer is D

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

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Correct Answer is C

Explanation

Choice C is correct because providing supplemental oxygen is the first action that the nurse should take for a client who has a suspected pulmonary embolus. A pulmonary embolus is a life-threatening condition that occurs when a blood clot travels to the lungs and blocks the blood flow, causing hypoxia and respiratory distress. The nurse should administer oxygen to improve the client's oxygenation and prevent further complications.

Choice A is incorrect because notifying the healthcare provider is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The nurse should notify the healthcare provider after providing supplemental oxygen and assessing the client's vital signs and symptoms.

Choice B is incorrect because preparing a continuous heparin infusion per protocol is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. Heparin is an anticoagulant that can prevent further clot formation and reduce the risk of recurrence, but it does not dissolve existing clots or improve oxygenation. The nurse should prepare a heparin infusion after obtaining a prescription from the healthcare provider and confirming the diagnosis with diagnostic tests.

Choice D is incorrect because bringing the emergency crash cart to the bedside is not the first action that the nurse should take for a client who has a suspected pulmonary embolus. The emergency crash cart contains equipment and medications that can be used in case of cardiac arrest or other emergencies, but it does not address the immediate need of oxygenation. The nurse should bring the emergency crash cart to the bedside after providing supplemental oxygen and assessing the client's condition.

A. Consume foods with saturated fats. B. Walk 30 minutes per day. C. Use a salt substitute. D. Keep a food diary. E. Eat more canned vegetables. F. Include oatmeal for breakfast.

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

Explanation

Choice A: Consuming foods with saturated fats is not a healthy lifestyle change for a client with coronary artery disease, as this can increase the level of cholesterol and triglycerides in the blood, which can lead to plaque formation and narrowing of the arteries. Therefore, this statement indicates that the client needs additional education.

Choice B: Walking 30 minutes per day is a beneficial lifestyle change for a client with coronary artery disease, as this can improve the blood circulation, lower the blood pressure, and reduce the risk of heart attack and stroke. Therefore, this statement does not indicate that the client needs additional education.

Choice C: Using a salt substitute is a helpful lifestyle change for a client with coronary artery disease, as this can reduce the sodium intake, which can lower the blood pressure and prevent fluid retention. Therefore, this statement does not indicate that the client needs additional education.

Choice D: Keeping a food diary is a useful lifestyle change for a client with coronary artery disease, as this can help the client monitor their calorie intake, portion size, and nutritional quality of their food. This can also help the client identify and avoid unhealthy food choices. Therefore, this statement does not indicate that the client needs additional education.

Choice E: Eating more canned vegetables is not a good lifestyle change for a client with coronary artery disease, as canned vegetables often contain high amounts of sodium, which can raise the blood pressure and worsen the condition. Therefore, this statement indicates that the client needs additional education.

Choice F: Including oatmeal for breakfast is an advantageous lifestyle change for a client with coronary artery disease, as oatmeal contains soluble fiber, which can lower the cholesterol level and prevent plaque formation in the arteries. Therefore, this statement does not indicate that the client needs additional education.

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Naxlex Comprehensive Predictor Exams

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

Correct Answer is C

Explanation

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

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

Explanation

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm and three fingerbreadths above the umbilicus. What action should the nurse implement first?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRS

Text 1:The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.)

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)