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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This client has a very high BNP level, which indicates severe heart failure and fluid overload. The nurse should follow up with this client first, as they may need urgent interventions such as oxygen therapy, diuretics, and vasodilators.
Choice B Reason: This client has an INR within the therapeutic range for warfarin therapy, which is usually between 2 and 3. The nurse should monitor this client for signs of bleeding or clotting, but they do not require immediate follow-up.
Choice C Reason: This client has a mildly elevated glucose level, which may be caused by the corticosteroids that
increase blood sugar. The nurse should check the client's blood glucose regularly and administer insulin as ordered, but they do not require immediate follow-up.
Choice D Reason: This client has a normal potassium level, which is within the reference range of 3.5 to 5 mEq/L. The nurse should ensure that the client is ready for dialysis and avoid foods high in potassium, but they do not require immediate follow-up.
Correct Answer is A
Explanation
Choice A Reason: This intervention is the most appropriate and effective for the nurse-manager to employ, as it provides clear and objective feedback to the staff nurse based on professional criteria, and encourages a positive and constructive approach to enhance the nurse's performance and development.
Choice B Reason: This intervention is not advisable, as it may create a false impression of the staff nurse's performance and fail to address the underlying issues or problems. Documenting the nurse's negative behaviors is important for accountability and improvement purposes, and avoiding it may expose the nurse manager to legal or ethical risks.
Choice C Reason: This intervention is not optimal, as it may demoralize or discourage the staff nurse and create a negative or hostile work environment. Focusing only on the areas of weakness may overlook the strengths and potential of the staff nurse, and may not foster a supportive and collaborative relationship between the nurse- manager and the staff nurse.
Choice D Reason: This intervention is not relevant, as it may divert the attention from the staff nurse's performance and shift the blame to external factors. Discussing how the inconsistency in the staff nurse's performance disrupts the routine of all of the staff members on the unit may not help the staff nurse identify and address their own areas of improvement, and may cause resentment or conflict among the team.
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