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 D

Explanation

Choice A rationale

Assigning the newly hired UAP to clients who require the least complex level of care might not be the best approach. While it might seem logical to assign less complex cases to a new hire, this could limit the UAP’s opportunities for learning and growth.

Choice B rationale

Reviewing the UAP’s skills checklist and experience with the person who hired the UAP is an important step, but it might not be enough to ensure adequate care for all clients. The skills and experiences listed on a checklist might not fully reflect the UAP’s actual abilities in a real-world setting.

Choice C rationale

Asking the most experienced UAP on the team to partner with the newly hired UAP could be beneficial for mentorship and guidance. However, this might not be the most efficient use of resources, especially if the experienced UAP has to spend a significant amount of time supervising the new hire.

Choice D rationale

Assessing the newly hired UAP’s competency level by observing the UAP deliver care is the most effective way to ensure adequate care for all clients. This allows the nurse to directly evaluate the UAP’s skills and abilities in a real-world setting, and to provide immediate feedback and guidance as needed.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral pressure injury with defined margins.

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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Naxlex Comprehensive Predictor Exams

A newly recruited unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.What intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

A patient with metastatic cancer who was taking hydromorphone orally at home is now receiving the medication intravenously while in the hospital.To evaluate if the patient is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete?

On the first day at 1830, certain medical procedures were initiated for the patient.Which of the following procedures were likely to have been initiated based on the patient’s condition?

Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

A nurse is assessing a 3-month-old patient who underwent a pyloromyotomy the previous day.Which of the following findings would indicate a need for pain medication? Select all that apply.

The nurse is teaching an older client about the prevention of osteoporosis.Which foods should the nurse recommend to the client to increase in the diet?