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 A
Explanation
Rationale:
A. "The client must provide permission to share the records with you." is the correct procedure as medical records are confidential and require patient consent for release to family members.
B. I will ask the nursing supervisor to obtain the medical records for you is not correct unless the client has given permission.
C. The health care provider will share this information with you does not address the need for patient consent.
D. The ethics committee will need to approve this request for you is not applicable; consent from the client is required.
Correct Answer is D
Explanation
Rationale:
A. Assigning an RN to perform a central line dressing change is appropriate as it requires specialized skills and knowledge.
B. Assigning an AP to perform glucometer monitoring is within their scope of practice and is a suitable task.
C. Assigning two APs to ambulate clients is reasonable if the workload requires it.
D. Assigning a new graduate nurse to perform a wet-to-dry dressing change may be inappropriate if it requires more experience and skill than the new graduate has.
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