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 C

Explanation

Choice A rationale
Moon facies, characterized by a round face, is a side effect of long-term use of prednisone. However, it is not the most important symptom for the client to report to the healthcare provider in this context.
Choice B rationale
Abdominal striae, or stretch marks on the abdomen, can also be a side effect of long-term use of prednisone. While it may be a concern for some patients due to cosmetic reasons, it is not the most critical symptom to report in this case.
Choice C rationale
Gastric irritation is a common side effect of prednisone and can lead to more serious complications such as gastric ulcers if not addressed promptly. Therefore, it is the most important symptom for the client to report to the healthcare provider.
Choice D rationale
Rapid weight gain can be a side effect of prednisone use. While it is important to monitor weight while on this medication, it is not the most critical symptom to report in comparison to gastric irritation.

A. Offer the client oral fluids B. Feed the client a snack C. Assess the breath sounds D. Empty the urinary drainage bag

Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with gout in the left great toe has received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom is most important for the client to report to the healthcare provider?

Correct Answer is C

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is D

Explanation

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.

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes. How should the nurse respond?

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.

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The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes. Which behaviors should the nurse prioritize for monitoring?