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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale: Recording the client's pulse volume distal to the IV site is a nursing responsibility as it involves an assessment of circulation.

Choice B rationale: Reapplying cold compresses is a task that UAP can perform to help minimize swelling and discomfort at the extravasation site.

Choice C rationale: Disposing of the IV tubing after the infusion is discontinued is a nursing responsibility to ensure proper disposal and prevent contamination.

Choice D rationale: Teaching the client about the need to keep the extremity elevated involves patient education and is within the scope of nursing practice.

A. Instruct the UAP to ask the visitor to get off the client's bed. B. Discuss why visitors should not lie in the bed with the client. C. Explain that the client has the right to have a visitor lie on the bed. D. Notify the charge nurse that the visitor is lying on the client's bed.

Correct Answer is C

Explanation

Choice A rationale: Instructing the UAP to ask the visitor to get off the client's bed is not within the UAP's scope of practice and may cause conflict.

Choice B rationale: While education about infection control and respect for the client's environment is important, it's essential to prioritize the client's autonomy and preferences regarding their visitors.

Choice C rationale: Clients have rights to decide who can be in their personal space, including their bed. As long as the visitor is not posing a risk to the client's safety or health, the client's wishes should be respected.

Choice D rationale: Notifying the charge nurse about the visitor lying on the bed is a reasonable action, but the immediate intervention is to ask the visitor to get off the bed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse determines that an intravenous (IV) vesicant chemotherapy infusion is infiltrated. In responding to this finding, which task can the nurse delegate to the unlicensed assistive personnel (UAP)?

Correct Answer is B

Explanation

Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?

Correct Answer is C

Explanation

The receptionist working in an outpatient clinic provides the nurse with a list of clients who need a return call from the nurse. The nurse should call the client with which description first?

Four clients are scheduled to receive IV infusions, but there are only three IV pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse delegate to the PN?