A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells (PRBCs). When notifying the healthcare provider (HCP), which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?

Explain specific reason for urgent notification

Obtain a PRN prescription for acetaminophen for fever over 101°F (38.3°C)

Communicate the pretransfusion temperatures

Begin the report by stating the client’s name and admitting diagnosis

Answer and Explanation

The Correct Answer is A

Choice A reason: Explaining the reason for urgent notification (fever during PRBC transfusion) is critical first in SBAR, as it conveys the situation, identifying a potential transfusion reaction. This prioritizes the provider’s focus on a life-threatening issue, ensuring timely intervention to prevent complications like hemolysis.

Choice B reason: Obtaining a prescription for acetaminophen treats fever but is a recommendation, not the first SBAR step. The situation (fever during transfusion) must be communicated first to alert the provider, making this action secondary to explaining the urgent issue.

Choice C reason: Communicating pretransfusion temperatures is background data, not the first SBAR step. The situation (fever during transfusion) takes precedence, as it signals a potential reaction, and temperature context follows, making this information less immediate than the reason for notification.

Choice D reason: Starting with the client’s name and diagnosis is part of background, not the first SBAR step. The situation (fever during transfusion) must be stated first to highlight urgency, ensuring the provider addresses the potential reaction promptly, making this less critical initially.

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Correct Answer is B

Explanation

Choice A reason: Measuring intake and output monitors fluid balance but does not address blood clots obstructing TURP drainage. Clots risk bladder distension or hemorrhage, and increasing irrigation flow directly clears the tubing, making this action secondary to preventing immediate complications in post-prostate surgery.

Choice B reason: Increasing bladder irrigation flow is the best initial action, as blood clots in TURP drainage indicate clot formation, risking obstruction. Faster irrigation flushes clots, preventing bladder distension or bleeding, maintaining catheter patency, and ensuring postoperative stability, making it the priority intervention.

Choice C reason: Providing oral fluids increases urine output but does not directly clear blood clots in TURP drainage. Clots require irrigation adjustment to prevent obstruction, and oral hydration is secondary, as it does not address the immediate risk of catheter blockage or bladder complications.

Choice D reason: Administering an antispasmodic addresses bladder spasms but not blood clots in TURP drainage. Clots cause obstruction, not spasms, and increasing irrigation flow directly resolves the issue, making antispasmodics irrelevant for the immediate problem of maintaining catheter patency.

A. Tracheostomy placement B. Central line insertion C. Nasogastric tube (NGT) insertion D. Pacemaker placement

Correct Answer is C

Explanation

Choice A reason: Tracheostomy placement is for prolonged airway management, not immediate in traumatic brain injury (TBI). NGT insertion addresses acute needs like gastric decompression or feeding, as TBI may impair swallowing, making this procedure less urgent than managing intracranial complications.

Choice B reason: Central line insertion provides vascular access but is not specific to TBI. NGT insertion prevents aspiration or manages gastric contents, critical in TBI with altered consciousness, making central lines secondary, as they address fluid or medication needs, not TBI-specific issues.

Choice C reason: NGT insertion is anticipated, as traumatic brain injury often impairs swallowing or consciousness, increasing aspiration risk. The tube decompresses the stomach or delivers nutrition, preventing complications like pneumonia, making it a priority procedure to support TBI management and patient stability.

Choice D reason: Pacemaker placement addresses cardiac arrhythmias, unrelated to traumatic brain injury. NGT insertion manages gastric or nutritional needs in TBI, where neurological deficits are primary, making pacemakers irrelevant, as TBI does not typically involve acute cardiac conduction issues.

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Naxlex Comprehensive Predictor Exams

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Correct Answer is B

Explanation

A client is admitted to the intensive care unit (ICU) with a traumatic brain injury. Which invasive procedure should the nurse anticipate preparing the client to undergo?

Correct Answer is C

Explanation

A client with suspected increased intracranial pressure (ICP) exhibits clinical manifestations of Cushing’s triad. Which assessment finding would the nurse expect to observe?

A client with diabetes mellitus is admitted with an acute hyperglycemic episode. Which intervention should the nurse implement?

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A client is admitted with sudden abdominal pain and possible acute pancreatitis. Which serum laboratory test result(s) should the nurse monitor? (Select all that apply)

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