A patient who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation.
When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, what information should the nurse provide first?
Client’s healthcare power of attorney.
Currently prescribed medications.
Fall at home as reason for admission.
Increasing confusion of the patient.
The Correct Answer is D
Choice A rationale
While the client’s healthcare power of attorney is important information, it is not the most critical piece of information to report in this situation. The immediate concern is the client’s change in mental status and potential medical emergency.
Choice B rationale
The nurse should be aware of the client’s currently prescribed medications, but this information does not take precedence over the client’s sudden onset of confusion and agitation. Immediate action is needed to address the client’s altered mental status.
Choice C rationale
While the reason for the client’s admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client’s acute change in mental status.
Choice D rationale
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client’s immediate needs.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
While the frequency of a problem can provide some context, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency of a problem does not necessarily correlate with the quality or relevance of the evidence available.
Choice B rationale
Personal values are important in decision-making processes, but they are subjective and can vary greatly among individuals. Therefore, they are not the most important consideration when gathering objective, scientific evidence for evidence-based practice.
Choice C rationale
Relevance to the situation is the most important consideration when gathering evidence. Evidence must be directly applicable to the specific problem and context in order to be useful in informing decision-making. This includes considering the specific characteristics of the patient population, the nature of the problem, and the setting in which care is being provided.
Choice D rationale
Past experience with similar problems can provide valuable insights and context, but it is not the most important consideration. Past experiences are individual and subjective, and what worked in one situation may not work in another. Evidence-based practice requires the use of current, high-quality research evidence, which may or may not align with past experiences.
Correct Answer is D
Explanation
Choice D rationale
In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.
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