A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family requests an update on the client's condition. Using the SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Increasing confusion of the client.

Client's healthcare power of attorney.

Currently prescribed medications.

Fall at home as reason for admission.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.

Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.

Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.

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Correct Answer is B

Explanation

Choice A Reason: The ability to update the equipment each year may be desirable, but not the most important question to consider. Updating the equipment may incur additional costs and may not be necessary or feasible depending on the type and function of the equipment.

Choice B Reason: The number of departments that can use the equipment is the most important question to

consider, as it reflects the potential impact and benefit of the equipment for the organization. The more departments that can use the equipment, the more efficient and cost-effective it will be.

Choice C Reason: The cost of equipment is an important question to consider, but not the most important one. The cost of equipment should be compared with the expected benefits and outcomes of using the equipment, not just in terms of monetary value, but also in terms of quality of care and patient satisfaction.

Choice D Reason: The need for annual repair is an important question to consider, but not the most important one. The need for annual repair may indicate the reliability and durability of the equipment, but it may also depend on the frequency and intensity of use, and the availability and accessibility of maintenance services.

A. Call the hospital operator to determine if this is indeed a real emergency or a fire drill. B. Instruct the clients' family members to stay in the visitor waiting area until further notice. C. Direct the nursing staff to evacuate the clients using the stairs in a calm and orderly manner. D. Tell the staff to keep all clients and visitors in the client rooms with the doors closed.

Correct Answer is D

Explanation

Choice A Reason: This action is not a priority, as it may delay the response to a potential fire. The charge nurse should assume that the fire alarm is real and act accordingly.

Choice B Reason: This action may expose the clients' family members to smoke or fire, as the visitor waiting area may not be safe. The charge nurse should ensure that everyone is in a protected area.

Choice C Reason: This action may be dangerous, as the stairs may be filled with smoke or fire. The charge nurse should follow the hospital's fire safety protocol, which usually involves closing doors, windows, and vents to prevent the spread of fire.

Choice D Reason: This action is the most appropriate, as it follows the RACE acronym for fire safety: Rescue anyone in immediate danger, Alarm by activating the fire alarm system, Contain by closing doors and windows, and Extinguish or evacuate as directed.

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Naxlex Comprehensive Predictor Exams

A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

Correct Answer is B

Explanation

The fire alarm goes off while the charge nurse is receiving the shift report. Which action should the charge nurse implement first?

Correct Answer is D

Explanation

A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

The nurse manager decides to report a staff nurse to the Peer Review Committee (PRC). Which activity merits this action?

The nurse manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse manager respond?

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?

A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?