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. When opening a sterile package or tray, the top flap should be opened away from the body to prevent contamination from the nurse’s uniform. Opening the flap toward the body risks breaking sterile technique, which is especially critical during procedures like thoracentesis. This is a break in sterile field, and the nurse manager should intervene immediately to prevent potential infection.
B. Using clean gloves is appropriate for non-sterile tasks like discontinuing an IV infusion.
C.The telephone number is considered an acceptable identifier according to The Joint Commission if it is in the medical record and used in combination with another identifier (like full name or date of birth).
D. Emptying a colostomy pouch when it is one-third full is appropriate practice to prevent overflow and maintain hygiene.
Correct Answer is A
Explanation
Rationale:
A. The client should sign the informed consent if they are alert, oriented, and capable of making decisions. The client's ability to understand the procedure and its implications is key to valid informed consent.
B. The client's son, who has a durable power of attorney would only sign the consent if the client were not competent or unable to understand the procedure, which is not the case here.
C. The client's partner may be involved in the decision-making process but does not have the legal authority to sign the consent unless designated as a legal representative.
D. The client's daughter, who is the primary caregiver would also not have the legal authority to sign the consent unless she holds a durable power of attorney or the client is deemed incapable of giving consent.
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