The nurse notifies the healthcare provider related to client information using the Situation, Background, Assessment, Recommendation (SBAR) technique. Which information should the nurse provide first?
Prescription for ceftriaxone PO every 12 hours.
A 26-year-old client.
Blood pressure is 80/48 mm Hg.
Admitted after a motor vehicle collision.
The Correct Answer is C
A. Prescription for ceftriaxone PO every 12 hours is not relevant in the initial "Situation" section of SBAR. This would fit better under the "Recommendation" or "Background" sections.
B. A 26-year-old client is part of the background information but does not immediately address the critical issue requiring attention.
C. Blood pressure is 80/48 mm Hg is the most urgent information and provides a clear reason for contacting the healthcare provider.
D. Admitted after a motor vehicle collision is part of the background and would follow the situation statement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Call the nearest relative to come in and sign a new form is not the correct course of action. While family involvement may be important, the priority is to address the error in the consent form before proceeding with the surgery. The healthcare provider must be informed to ensure the correct procedure is performed.
B. Call the healthcare provider (HCP) to have the procedure rescheduled is the most appropriate action. The error in the consent form and the discrepancy between the consent and the surgical site marking must be addressed immediately to prevent a potentially catastrophic mistake. The healthcare provider will need to correct the error and ensure proper documentation before proceeding with surgery.
C. Have the client sign another form before surgery is not appropriate because the client has already been administered opioid medication, which may impair their ability to make informed decisions. The error in the consent form must be resolved with the healthcare provider before the client signs anything.
D. Cross out the error and initial the consent form is not an appropriate action. This could be seen as tampering with the document, and it does not resolve the issue of the incorrect surgical site. A new consent form must be signed after the error is corrected.
Correct Answer is A
Explanation
A. Clean the urinary meatus before retracting the foreskin is the correct action. Before retracting the foreskin, the nurse should clean the meatus to prevent contamination of the catheterization site. This ensures that any bacteria present are removed before inserting the catheter.
B. Position the sterile field even with the nurse's hips is not directly related to the procedure for an uncircumcised male client. The sterile field should be positioned at a level where the nurse can comfortably reach it without contaminating it, but this does not specifically address the care of an uncircumcised male.
C. Use a swab to wipe the meatus in back-and-forth motions is incorrect. The meatus should be cleaned using a circular motion, starting at the meatus and working outward. Back-and-forth motions could cause contamination of the area.
D. Advance the catheter before inflating the balloon is an appropriate action during catheter insertion; however, this is not specific to the care of an uncircumcised male client. The balloon should be inflated only after the catheter is fully inserted and urine flow is confirmed.
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