An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Fall at home as the reason for admission.

Increasing confusion of the client.

Client's healthcare power of attorney.

Currently prescribed medications.

Answer and Explanation

The Correct Answer is B

Choice A reason: While the fall is important, it is not the most immediate concern for the healthcare provider in the context of SBAR communication.

Choice B reason: Increasing confusion can indicate a change in the client's condition and may require immediate intervention, making it the priority in SBAR communication.

Choice C reason: The client's healthcare power of attorney is important for legal and consent purposes but is not the first piece of information to provide in an SBAR report.

Choice D reason: Currently prescribed medications are part of the background information and would follow after the immediate situation has been described.

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Correct Answer is B

Explanation

Choice A reason:Deferring to the provider does not address the confidentiality issue; it suggests the nurse is unwilling rather than clarifying the legal obligation to protect an adult client’s health information.

Choice B reason: By stating that only the client can authorize release of their own medical data, the nurse accurately reflects HIPAA and patient‑privacy regulations for an adult. This response both informs the parent and upholds the client’s right to confidentiality.

Choice C reason: This response is inappropriate and unprofessional. It fails to acknowledge the parent's concern and does not provide a constructive way to address the situation.

Choice D reason: While this response may seem helpful, it is not the nurse's role to promise lab results, especially when there are privacy laws that restrict the sharing of medical information with anyone other than the patient unless consent has been given.

A. Measure body temperature. B. Assess skin turgor. C. Check for pedal edema. D. Observe the color of urine.

Correct Answer is D

Explanation

Choice A reason: Measuring body temperature is a standard procedure but not directly related to monitoring for adverse effects of prasugrel, which primarily include bleeding complications.

Choice B reason: Assessing skin turgor is generally used to evaluate hydration status and is not specific to prasugrel's adverse effects.

Choice C reason: Checking for pedal edema can indicate heart failure or vascular problems but is not a direct indicator of prasugrel's adverse effects.

Choice D reason: Observing the color of urine is important as prasugrel can cause significant and sometimes fatal bleeding. Dark or bloody urine may be an early indicator of such bleeding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 22-year-old client is admitted to the hospital in diabetic ketoacidosis (DKA). The client's parent is insisting on knowing the laboratory test results. Which is the best response for the nurse to provide?

Correct Answer is B

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

Patient Data: Exhibits Review H and P and laboratory results. Based on the laboratory data, the client has dropdown related to dropdown

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