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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: An adult client with a tracheal tube draining clear, pale red liquid drainage. This client should not be assessed last, as they may have a potential airway obstruction or infection. The tracheal tube drainage should be monitored for color, amount, and consistency, and suctioned as needed.
Choice B: An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. This client should not be assessed last, as they may have a potential hemorrhage or wound dehiscence. The postoperative dressing and Hemovac should be monitored for color, amount, and odor, and changed as needed.
Choice C: An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client can be assessed last, as they have no signs of complications or problems. The Jackson-Pratt drain is a closed suction device that collects fluid from a surgical site. The bulb should be compressed to create negative pressure and facilitate drainage.
Choice D: An older client with a distended abdomen and no drainage from the nasogastric tube. This client should not be assessed last, as they may have a potential bowel obstruction or perforation. The nasogastric tube is inserted through the nose into the stomach to decompress gas and fluid. The abdomen should be monitored for size, shape, and bowel sounds, and the nasogastric tube should be checked for patency and placement.
Correct Answer is D
Explanation
Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.
Choice B reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.
Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.
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