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. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is the most critical task to ensure that the infant is safe and that the postoperative care is being managed correctly.

B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma is less urgent compared to tasks directly related to patient safety and postoperative care.

C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking the safety equipment for a postoperative infant.

D. Engage a toddler in play is beneficial but less urgent than tasks related to immediate postoperative care and safety.

A. Ask the AP about her concerns with the assignment. B. Report the AP to the charge nurse. C. Take the specimen to the laboratory. D. Complete an incident report.

Correct Answer is A

Explanation

Rationale:

A. Ask the AP about her concerns with the assignment is appropriate as it allows the nurse to understand and address any potential issues or reasons for refusal.

B. Report the AP to the charge nurse should only be done if the refusal cannot be resolved through discussion.

C. Take the specimen to the laboratory should be done if needed, but it is important to first understand why the AP refused.

D. Complete an incident report might be premature without understanding the reason behind the refusal.

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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 A

Explanation

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Correct Answer is A

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