A nurse is caring for a client who is postoperative.

Exhibits

Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply

Medication for elevated temperature

Insertion of NG tube for decompression

Oxygen 2 to 4 L/min via nasal cannula

Insertion of urinary catheter

Evaluation of surgical wound drain

Answer and Explanation

Correct Answer : A,E

A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.

B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.

C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.

D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.

E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.

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Correct Answer is A

Explanation

Rationale:

A. Demonstrating and observing the staff using the device ensures that they can correctly operate the equipment and apply their learning practically.

B. Reviewing the procedure manual is helpful but does not ensure hands-on competency.

C. A written brochure provides information but does not involve practical application.

D. Providing a written procedure is useful but does not confirm that staff can use the device correctly in practice.

A. Prescribing naloxone to reverse the effects of the morphine B. Asking the client to sign the surgical consent form C. Delaying the surgery until a member of the client's family is reached D. Invoking implied consent

Correct Answer is D

Explanation

Rationale:

A. Naloxone would reverse morphine effects, which is not relevant to the immediate need for surgical intervention.

B. The client might not be able to sign the consent if under the effects of morphine, and obtaining consent might be delayed.

C. Delaying surgery might not be appropriate if the client’s condition is critical and requires urgent intervention.

D. Implied consent is used in emergencies when a patient cannot provide consent due to their condition, and it is assumed they would consent to life-saving treatment.

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A nurse is caring for a client who is postoperative. Exhibits Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply

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A nurse is caring for a client who is postoperative.

Exhibits

Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply