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 D

Explanation

Rationale:

A. WBC 6,000/mm³ is within normal range and does not require follow-up.

B. BUN 15 mg/dL is within normal range and does not require follow-up.

C. Hemoglobin 14 g/dL is within normal range for most adults and does not require follow-up.

D. Platelet count 60,000/mm³ is significantly low and requires follow-up as it can increase the risk of bleeding during surgery.

A. Dilated pupils B. Euphoria C. Rhinorrhea D. Hallucinations

Correct Answer is B

Explanation

Rationale:

A. Dilated pupils are typically associated with stimulant use, not opioids.

B. Euphoria is a common effect of opioid use and can indicate misuse or diversion of these medications.

C. Rhinorrhea is usually associated with withdrawal from opioids rather than their use.

D. Hallucinations can occur with certain drugs but are less commonly associated with opioid use compared to euphoria.

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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

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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