A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cells. When notifying the healthcare provider, which information should the nurse provide first using the SBAR (Situation, Background, Assessment, and Recommendation) communication process?

Explain specific reason for urgent notification.

Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C).

Preface the report by stating the client’s name and admitting diagnosis.

Communicate the pre-transfusion temperatures.

Answer and Explanation

The Correct Answer is C

Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.

Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

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Correct Answer is A

Explanation

Choice A reason: Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client’s plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.

Choice B reason: Frequently evaluating the client’s pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Evaluating the client’s pain can help the nurse to assess the effectiveness of the analgesics, identify the characteristics and causes of the pain, and adjust the pain management plan accordingly. However, evaluating the pain alone is not enough to provide pain relief, and the nurse should also implement the appropriate interventions based on the evaluation.

Choice C reason: Replacing transdermal analgesic patches every 72 hours is not a relevant intervention that the nurse should include in this client’s plan of care, because it is not applicable to the client’s situation. Transdermal analgesic patches are a form of opioid delivery that can provide long-lasting pain relief, but they are not suitable for acute or breakthrough pain, and they have a delayed onset of action. The client in this scenario is receiving IV analgesics, which have a faster onset and shorter duration of action, and are more appropriate for acute or breakthrough pain.

Choice D reason: Monitoring the client for break-through pain is an important intervention that the nurse should include in this client’s plan of care, but it is not the most important one. Break-through pain is a sudden and transient increase in pain that occurs despite the use of regular analgesics, and it can be caused by various factors, such as movement, infection, or tumor progression. The nurse should monitor the client for break-through pain and administer rescue doses of analgesics as needed. However, monitoring the client for break-through pain is not enough to prevent or treat the pain, and the nurse should also administer analgesics on a fixed and continuous schedule to maintain a steady level of pain relief.

A. Log roll the client and place adult disposable briefs beneath the client. B. Maintain traction while the client uses a urinal. C. Release the traction so the client can use a bedpan. D. Insert an indwelling urinary catheter preoperatively.

Correct Answer is B

Explanation

Choice A reason: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

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Naxlex Comprehensive Predictor Exams

A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client’s plan of care?

Correct Answer is A

Explanation

A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Correct Answer is B

Explanation

A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?

An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?

The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action about skin care indicates a need for further teaching?

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?