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 C

Explanation

Rationale:

A. Providing appropriate resources is an outcome of effective delegation but not its primary purpose.

B. Promoting discharge teaching is not the primary purpose of delegation; it’s more about ensuring tasks are appropriately assigned.

C. Delegation permits a designated individual to meet a goal on your behalf, accurately reflecting the purpose of delegating tasks to others to achieve client care goals efficiently.

D. Decreasing health care costs may be an indirect benefit, but it is not the primary purpose of delegation.

A. A client who has Guillain-Barre syndrome B. A client who has a lumbosacral spinal tumor C. A client who has systemic sclerosis D. A client who has amyotrophic lateral sclerosis (ALS)

Correct Answer is B

Explanation

Rationale:

A. A client who has Guillain-Barre syndrome requires close monitoring and specialized care due to progressive weakness and potential respiratory issues. This client's care may involve more complex needs that are beyond the AP's scope.

B. A client who has a lumbosacral spinal tumor is likely to have fewer immediate needs related to eating assistance, making this task appropriate to delegate to the AP. The client’s primary concern may be mobility or pain management, but meal assistance is a routine task.

C. A client who has systemic sclerosis may have issues with gastrointestinal motility and swallowing, requiring more careful feeding assistance and monitoring, which should be performed by the nurse.

D. A client who has amyotrophic lateral sclerosis (ALS) requires specialized care for swallowing difficulties and respiratory issues, making it inappropriate to delegate meal assistance to the AP.

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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

A nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?

Correct Answer is C

Explanation

A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?

Correct Answer is B

Explanation

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A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

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