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: Isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action that the nurse should take, because it can prevent the transmission of COVID-19, which is a highly contagious respiratory disease caused by a novel coronavirus. The client has symptoms that are consistent with COVID-19, such as conjunctivitis, loss of taste and smell, and recent travel history, and the nasal swab test can confirm the diagnosis. The nurse should follow the infection control precautions, such as wearing a mask, gloves, gown, and eye protection, and place the client in a private room with negative pressure ventilation, if available.

Choice B reason: Reporting the COVID-19 result to the local health department according to CDC guidelines is an important action that the nurse should take, but it is not the most important one. Reporting the COVID-19 result can help the public health authorities to monitor the epidemiology, track the contacts, and implement the interventions to control the outbreak. However, reporting the result can only be done after the test is completed and confirmed, which may take some time. The nurse should prioritize the immediate isolation of the client to prevent the spread of the virus.

Choice C reason: Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is an important action that the nurse should take, but it is not the most important one. Teaching the client to wear a mask, hand wash, and social distance can help the client to protect themselves and others from COVID-19, which can be transmitted through respiratory droplets, contact, and aerosols. However, teaching the client these measures can only be effective if the client follows them and adheres to the isolation guidelines. The nurse should first isolate the client and then provide the education.

Choice D reason: Explaining to the client to inform others that they may have been potentially exposed in the last 14 days is an important action that the nurse should take, but it is not the most important one. Explaining to the client to inform others that they may have been potentially exposed in the last 14 days can help the client to notify their close contacts, such as family, friends, co-workers, and travel companions, who may have been at risk of COVID-19 infection. However, explaining to the client this information can only be useful if the client cooperates and remembers their contacts. The nurse should first isolate the client and then assist the client with the contact tracing.

A. Apical heart rate of 100 to 110 beats/minute. B. Redness and edema noted at the incision site. C. High-pitched sound heard upon inspiration. D. Pain rating of 8 on a scale of 1 to 10.

Correct Answer is C

Explanation

Choice A reason: An apical heart rate of 100 to 110 beats/minute is not unusual after surgery, as the client may be experiencing stress, pain, or anxiety. This finding does not require immediate action by the nurse, but should be monitored and reported if it persists or worsens.

Choice B reason: Redness and edema at the incision site are expected signs of inflammation and healing after surgery. This finding does not require immediate action by the nurse, but should be assessed for signs of infection, such as pus, warmth, or foul odor.

Choice C reason: A high-pitched sound heard upon inspiration, also known as stridor, is a sign of upper airway obstruction, which can be life-threatening. This finding requires immediate action by the nurse, such as administering oxygen, suctioning, or calling for help.

Choice D reason: A pain rating of 8 on a scale of 1 to 10 indicates severe pain, which can affect the client's recovery and comfort. This finding requires prompt action by the nurse, such as administering analgesics, repositioning, or providing non-pharmacological interventions. However, this is not as urgent as choice C, which involves the client's airway.

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Naxlex Comprehensive Predictor Exams

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?

Correct Answer is C

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?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

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?

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?

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?

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?

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?

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?