A client has undergone a surgical procedure and develops a weak, rapid pulse.
Which intervention should the nurse recommend to provider during their SBAR communication?
Anticholinergic.
Urinary catheter placement.
Beta blocker.
Intravenous fluid bolus.
The Correct Answer is D
A weak, rapid pulse indicates that the client is experiencing hypovolemia or low blood volume due to blood loss during surgery.
The nurse should recommend to the provider to administer intravenous fluids to restore the client’s circulating volume and improve their hemodynamic status.
Choice A is wrong because anticholinergics are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the parasympathetic nervous system.
Anticholinergics can cause tachycardia, dry mouth, urinary retention, and blurred vision. They are not indicated for hypovolemia.
Choice B is wrong because urinary catheter placement is not a priority intervention for a client with hypovolemia.
Urinary catheterization can help monitor urine output and renal perfusion but does not address the underlying cause of low blood volume.
Choice C is wrong because beta blockers are drugs that block the action of epinephrine and norepinephrine, neurotransmitters that stimulate the sympathetic nervous system.
Beta-blockers can lower blood pressure, heart rate, and cardiac output.
They are not indicated for hypovolemia and can worsen the client’s condition.
To communicate this information using the SBAR tool, the nurse should follow these steps: Situation: Identify yourself, the client, and the problem.
For example: “I am (name), the nurse caring for (client name) in room (number).
I am calling because I am concerned that the client has developed hypovolemia after surgery.”
Background: Provide relevant and brief information related to the situation.
For example: “The client had a surgical procedure (name and type) at (time) today. They have lost (amount) of blood during and after surgery.
Their current vital signs are: blood pressure (value), pulse (value), respiratory rate (value), temperature (value), oxygen saturation (value).”
Assessment: Share your analysis and considerations of options. For
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
Correct Answer is ["B","C","E"]
Explanation
These interventions are based on the principles of sleep hygiene and cognitive behavioral therapy for insomnia (CBT-I), which are evidence-based strategies to promote better sleep.
Choice A is wrong because alcohol can disrupt sleep quality and cause frequent awakenings during the night. It can also interfere with the normal sleep cycle and reduce REM sleep.
Choice D is wrong because reading a book 30 minutes before bedtime can be stimulating and make it harder to fall asleep. It can also violate the stimulus control therapy, which aims to associate the bed only with sleep and sex and avoid any other activities that may keep the mind alert.
Some additional sentences are:
- Normal ranges for sleep vary depending on age, lifestyle, and individual factors, but generally adul,ts need about 7 to 9 hours of sleep per night.
- Insomnia is a common sleep disorder that affects about 10% to 30% of adults and can have negative impacts on physical and mental health, as well as quality of life.
- If insomnia persists despite following these interventions, it is advisable to consult a doctor or a sleep specialist for further evaluation and treatment options.
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