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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

Hematocrit is a measure of the proportion of red blood cells in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.

Choice B rationale

Neutrophil count is a measure of the number of neutrophils, a type of white blood cell, in the blood. An elevated neutrophil count can indicate an infection, making it the most relevant lab value to check in this scenario.

Choice C rationale

Platelet count is a measure of the number of platelets in the blood. While platelets play a crucial role in blood clotting, they are not directly related to infection and therefore not the most relevant lab value to check in this scenario.

Choice D rationale

Serum sodium level is a measure of the amount of sodium in the blood. While it can be affected by various conditions, it is not the most relevant lab value to check when purulent drainage is noticed at a postoperative patient’s dressing site.

A. Place a certified copy of the living will in the patient’s record. B. Inform the healthcare provider of the patient’s wishes. C. Arrange a family meeting with the palliative care team. D. Notify the nursing staff of the patient’s do not resuscitate status.

Correct Answer is B

Explanation

Choice A rationale

While placing a certified copy of the living will in the patient’s record is important, it is not the immediate next step. The living will should be acknowledged, but the healthcare provider needs to be informed immediately.

Choice B rationale

Informing the healthcare provider of the patient’s wishes is the most appropriate next step. The healthcare provider can then make decisions based on the patient’s expressed wishes.

Choice C rationale

Arranging a family meeting with the palliative care team may be beneficial, but it is not the immediate next step. The healthcare provider needs to be informed first.

Choice D rationale

Notifying the nursing staff of the patient’s do not resuscitate status is important, but it is not the immediate next step. The healthcare provider needs to be informed first.

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Naxlex Comprehensive Predictor Exams

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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