A nurse is caring for a client who is postoperative.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "I had strep throat about one year ago" is not directly related to contraindications for glyburide.
B. "I got my flu shot at the pharmacy two weeks ago" does not affect the use of glyburide.
C. "I plan to continue nursing my baby until he is at least a year old" indicates a contraindication because glyburide is not recommended for use during breastfeeding due to potential effects on the infant.
D. "I am allergic to shellfish" is not relevant to the contraindications for glyburide.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,C"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"},"G":{"answers":"A,C"}}
Explanation
Time Management: Concerns related to how the nurse manages their time, including the efficiency of their work and how they handle their responsibilities (e.g., frequent trips to the supply room, notes written on small pieces of paper, coming early and staying late to chart).
Delegation: Issues related to the nurse's ability to delegate tasks effectively (e.g., covering other nurses' clients for breaks, which could suggest issues with delegation).
Professional Behavior: Concerns related to the nurse's conduct and adherence to professional standards (e.g., frequent personal phone calls during shifts, not taking breaks, missed prescriptions, covering other nurses' clients without taking breaks).
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