A client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family presents the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
Client's healthcare power of attorney.
Increasing confusion of the client.
Currently prescribed medications.
Fall at home as reason for admission.
The Correct Answer is B
Choice A rationale: The assessment is the client's signed power of attorney and a home medication list, which are important documents that indicate the client's wishes and potential drug interactions. While the client's healthcare power of attorney is important information, the reason for admission should be provided first to give context to the situation.
Choice B rationale: The nurse should start by presenting the immediate situation or concern, which is the client's increasing confusion which needs immediate attention. Choice C rationale: The recommendation is the nurse's suggestion for further diagnostic tests, interventions, or referrals based on the situation, background, and assessment. The currently prescribed medications are relevant, but the primary reason for admission should be communicated first to establish the context of the client's condition. Choice D rationale: The background is the fall at home as the reason for admission, which explains the possible cause of the confusion and the loss of consciousness. This comes after the situation which is the increasing confusion.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale: Recording that the nurse questioned the prescription and seeking guidance from the supervisor can be done after calling the healthcare provider back.
Choice B rationale: Notifying the medical chief of staff may be necessary, but the nurse should first call the healthcare provider back.
Choice C rationale: Calling the healthcare provider back to report the dosage discrepancy is important, because it will allow the healthcare provider to correct the mistake and give a safe prescription.
Choice D rationale: Refusing to administer the medication and writing an incident report is an appropriate action, but it should be done if the healthcare provider does not respond or insists on giving the wrong prescription.
Correct Answer is B
Explanation
Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.
Choice B rationale:The nebulizer treatment should be administered FIRST to alleviate the clients obstructed airway (respiratory distress)
Choice C rationale: Evaluating the breathing pattern is important but should be done immediately after implementing physician orders
Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.
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