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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The correct answer is: c. Leave the light on in the room at night.

Choice A: Replace the IV catheter with a smaller gauge

Replacing the IV catheter with a smaller gauge is not directly addressing the issue of the client’s confusion and agitation. While a smaller gauge might be less irritating, it does not solve the problem of the client picking at the IV site. The pinkness at the IV site suggests mild irritation or early signs of phlebitis, which can be managed by monitoring and ensuring proper securement and care of the IV site.

Choice B: Apply soft bilateral wrist restraints

Applying wrist restraints should be a last resort due to the potential for causing distress, agitation, and physical harm to the patient. Restraints can lead to negative outcomes such as decreased circulation, pressure ulcers, and increased agitation, especially in patients with dementia. It is generally recommended to use less restrictive measures first.

Choice C: Leave the light on in the room at night

Leaving the light on in the room at night (C) can help reduce confusion and agitation in dementia patients, a phenomenon known as sundowning. However, it does not address the immediate issue of the non-occlusive dressing and the pink IV insertion site.

Choice D: Redress the abdominal incision

Given the situation, the most appropriate intervention would be to redress the abdominal incision (D). This is because the dressing is no longer occlusive, which can increase the risk of infection. Ensuring the dressing is secure and clean is crucial for the patient's safety.

A. Discuss the issue privately with the UAP. B. Note date and time of the behavior. C. Plan for scheduled break times. D. Evaluate the UAP for signs of improvement.

Correct Answer is B,A,C,D

Explanation

The correct order is:

- Note date and time of the behavior.

- Discuss the issue privately with the UAP.

- Plan for scheduled break times.

- Evaluate the UAP for signs of improvement.

Here are the reasons for this order:

- Note date and time of the behavior. This should be done first, as it can provide objective evidence of the UAP's behavior and its impact on patient care and staff workload. The unit manager should document any incidents or complaints related to the UAP's behavior in a factual manner.

- Discuss the issue privately with the UAP. This should be done second, as it can provide an opportunity for feedback and clarification. The unit manager should use a respectful and professional tone, and explain how the UAP's behavior affects patient safety and staff morale. The unit manager should also listen to any concerns or challenges that the UAP may have, and offer support or guidance as needed.

- Plan for scheduled break times. This should be done third, as it can provide a solution or prevention strategy for future occurrences. The unit manager should work with the UAP and other staff members to ensure that there are adequate breaks and coverage for patient care. The unit manager should also review any policies or procedures related to break times and staff attendance.

- Evaluate the UAP for signs of improvement. This should be done last, as it can provide a measure of effectiveness and accountability. The unit manager should monitor and document any changes in the UAP's behavior, performance, or attitude. The unit manager should also provide positive reinforcement or corrective action as appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is B,A,C,D

Explanation

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)

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

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take?

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which statement(s) should the nurse include in this client’s teaching plan? (Select all that apply.)

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD.?

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

The nurse leading a cardiac team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which task should the nurse assign to the PN?