An older client admitted for observation following a fall while getting out of the bathtub becomes increasingly confused. The family arrives with the home medication list and the client’s healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which 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 client.

Answer and Explanation

The Correct Answer is D

Choice A: Client’s healthcare power of attorney. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The healthcare power of attorney is a legal document that designates who can make medical decisions for the client if they are unable to do so themselves.

Choice B: Currently prescribed medications. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The currently prescribed medications are a part of the background information that can help explain the client’s medical history and potential causes of confusion.

Choice C: Fall at home as reason for admission. This is not the first information that the nurse should provide, as it does not address the current situation or problem of the client. The fall at home is a part of the background information that can help explain the client’s reason for admission and potential injuries.

Choice D: Increasing confusion of the client. This is the first information that the nurse should provide, as it addresses the current situation or problem of the client. The increasing confusion of the client is a part of the assessment information that can help identify the urgency and severity of the issue and guide further interventions.

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Correct Answer is A

Explanation

Choice A: Observing insertion site is an essential assessment for a client who has a suprapubic catheter. The insertion site is located in the lower abdomen, where urine drains from an opening in the bladder through a catheter into a drainage bag. The nurse should inspect the site for signs of infection, inflammation, bleeding, or leakage. The nurse should also clean the site with soap and water and apply a sterile dressing as needed.

Choice B: Palpating flank area is not a relevant assessment for a client who has a suprapubic catheter. The flank area is located on the sides of the back, where the kidneys are located. Palpating the flank area can detect tenderness or pain that may indicate kidney infection or stones, but it does not provide information about the suprapubic catheter or its function.

Choice C: Measuring abdominal girth is not a relevant assessment for a client who has a suprapubic catheter. The abdominal girth is the circumference of the abdomen at the level of the umbilicus. Measuring abdominal girth can detect changes in fluid balance, ascites, or bowel obstruction, but it does not provide information about the suprapubic catheter or its function.

Choice D: Assessing perineal area is not a relevant assessment for a client who has a suprapubic catheter. The perineal area is located between the anus and the genitals. Assessing perineal area can detect signs of infection, irritation, or injury in the genital or anal regions, but it does not provide information about the suprapubic catheter or its function.

A. Mark an outline of the “olive-shaped” mass in the right epigastric area. B. Initiate a continuous infusion of IV fluids per prescription. C. Monitor amount of intake and infant's response to feedings. D. Instruct parents regarding care of the incisional area.

Correct Answer is B

Explanation

Choice B is correct because initiating a continuous infusion of IV fluids per prescription has highest priority for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. Pyloric stenosis causes projectile vomiting and dehydration, which can lead to metabolic alkalosis and electrolyte imbalance. The infant needs IV fluids to correct these abnormalities and prevent complications.

Choice A is incorrect because marking an outline of the “olive-shaped” mass in the right epigastric area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The “olive-shaped” mass is a palpable sign of pyloric stenosis, but it does not require any intervention before surgery.

Choice C is incorrect because monitoring amount of intake and infant's response to feedings is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The infant may have difficulty feeding due to vomiting and gastric distension, which can worsen their dehydration and malnutrition. The infant may need to be kept NPO (nothing by mouth) before surgery.

Choice D is incorrect because instructing parents regarding care of the incisional area is not a priority action for an infant with pyloric stenosis who is scheduled for a pyloromyotomy. The incisional area will need proper care after surgery, but this can be taught later when the infant is stable and ready for discharge.

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Naxlex Comprehensive Predictor Exams

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter?

Correct Answer is A

Explanation

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has highest priority?

Correct Answer is B

Explanation

Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

After receiving report, the nurse can most safely plan to assess which client last?

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

The nurse is preparing a dose of 10 mg of teriparatide. The medication is labeled 760 mcg/2.4 mL. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding this client?

A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

The nurse is providing education to a client who experiences recurrent episodes of moderate anxiety to situations. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?