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 B

Explanation

Rationale:

A. Call the provider for a stat DNR order is not appropriate as the client is already in a critical state requiring immediate action.

B. Call the emergency response team is necessary as the client is pulseless, and resuscitation should be initiated according to standard procedures until a DNR order is confirmed.

C. Seek immediate help from the risk manager is not appropriate at this moment; the immediate concern is the client's emergency situation.

D. Respect the family's wishes and do nothing is not appropriate as immediate life-saving measures should be taken until a formal DNR order is in place.

A. Measure 1&O for a client who has an indwelling urinary catheter. B. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty. C. Develop a plan of care for a client who has cholecystitis. D. Complete an admission assessment for a client who has COPD.

Correct Answer is B

Explanation

Rationale:

A. Measuring I&O can be performed by an AP, as it does not require advanced skills or clinical judgment.

B. Reinforcing teaching about medication is within the LPN's scope of practice, as LPNs are trained to provide education and support based on the teaching provided by RNs or physicians.

C. Developing a plan of care is generally a responsibility of the RN, as it involves comprehensive assessment and planning.

D. Completing an admission assessment is a task for RNs due to its complexity and the need for a detailed clinical evaluation.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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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