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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["30"]
Explanation
First, we need to find the concentration of insulin in the IV solution, which is the ratio of insulin units to saline volume. To do this, we use the given information that the IV solution contains 100 units in 250 ml. So, we divide 100 by 250 and get 0.4 units/ml.
Next, we need to calculate the infusion rate in ml/hour for the ordered dose of 12 units/hour. To do this, we use the ratio of insulin units to saline volume, which is 0.4 units/ml. So, we set up a proportion as follows:
0.4/1=12/x
To solve for x, we cross-multiply and get 0.4 x = 12. Then, we divide both sides by 0.4 and get x = 30. So, the infusion rate is 30 ml/hour.
Therefore, the nurse should program the infusion pump to deliver 30 ml/hour..
Correct Answer is C
Explanation
Choice A: Yellow-tinged sputum is not a serious adverse effect of linezolid. It may indicate an infection or inflammation in the respiratory tract, but it does not require immediate attention from the health care provider.
Choice B: Nausea and headache are common side effects of linezolid. They are usually mild and self-limiting, and they can be managed with supportive measures such as hydration, rest, and analgesics.
Choice C: Watery diarrhea is a sign of pseudomembranous colitis, a potentially life-threatening complication of linezolid. It is caused by an overgrowth of Clostridium difficile bacteria in the colon, which produce toxins that damage the intestinal mucosa. It can lead to dehydration, electrolyte imbalance, sepsis, and perforation. The nurse should report this finding to the health care provider immediately and stop the linezolid infusion.
Choice D: Increased fatigue is not a specific or serious adverse effect of linezolid. It may be related to the underlying infection, anemia, or other factors. It does not require urgent intervention from the health care provider.
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