A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
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.

Fall at home as reason for admission.

Currently prescribed medications.

Increasing confusion of the client.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.

Choice B rationale:

While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.

Choice C rationale:

The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.

Choice D rationale:

Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.

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Correct Answer is D

Explanation

Choice D rationale:

"Antiembolism stockings on, leg exercises performed hourly" indicates that activities to prevent postoperative venous stasis were performed correctly. This combination ensures both mechanical prophylaxis (antiembolism stockings) and physical activity (leg exercises) to prevent blood clots in postoperative patients.

Choice A rationale:

"Leg exercises not performed because of placement of antiembolism hose" is not the correct approach. Leg exercises should be encouraged even when antiembolism stockings are worn, as they have complementary benefits in preventing venous stasis.

Choice B rationale:

"Antiembolism stockings removed hourly during leg exercises" is not recommended. Antiembolism stockings should be worn continuously to be effective in preventing venous stasis.

Choice C rationale:

"Client demonstrates the ability to move all extremities well" is a good sign of the client's mobility but does not confirm that the specific activities to prevent postoperative venous stasis were performed correctly. The combination of stockings and leg exercises is more comprehensive.

A. Diarrhea and flatulence. B. Muscle pain. C. Altered taste. D. Abdominal cramps.

Correct Answer is B

Explanation

Choice A rationale:

Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.

Choice B rationale:

Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.

Choice C rationale:

Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.

Choice D rationale:

Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.

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Naxlex Comprehensive Predictor Exams

Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

Correct Answer is D

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is B

Explanation

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