A patient is brought to the emergency department after falling from a ladder and is exhibiting signs of confusion and disorientation.

The spouse reports that the patient seemed to have lost consciousness.

The nurse has been provided with a list of current medications and healthcare power of attorney.

When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

The patient’s currently prescribed medications.

The increasing confusion of the patient.

The patient’s healthcare power of attorney.

The fall from a ladder as the reason for admission.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.

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Correct Answer is A

Explanation

Choice A rationale
Pregabalin is a medication used to treat nerve pain, particularly in conditions like diabetic peripheral neuropathy. A reduced level of pain would indicate that the medication is effective.
Choice B rationale
Improved visual acuity is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect vision.
Choice C rationale
Full volume of pedal pulses is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect circulation.
Choice D rationale
Granulating tissue in a foot ulcer is not a typical outcome of pregabalin treatment for diabetic peripheral neuropathy. Pregabalin does not typically affect wound healing.

A. Administer IV fluids B. Assess the rash C. Administer an antihistamine D. Administer a steroid

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.

They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.

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Naxlex Comprehensive Predictor Exams

A patient with diabetic peripheral neuropathy has been taking pregabalin for the past four days. Which finding would indicate to the nurse that the medication is effective?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client’s arm?

The nurse observes an unlicensed assistive personnel (UAP) preparing to provide personal care for a patient who requires contact precautions. The UAP has put on a gown and gloves and has secured the tops of the gloves over the gown sleeves. What action should the nurse take?

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

The nurse is educating a first-time pregnant woman about preeclampsia. Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.