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 C

Explanation

Choice A reason: Blood pressure, heart rate, and temperature are vital signs that should be monitored in any client, but they are not laboratory results. ESRD can cause hypertension and cardiovascular complications, so blood pressure and heart rate should be controlled with medications and lifestyle modifications. Temperature should be monitored for signs of infection or inflammation.

Choice B reason: Leukocytes, neutrophils, and thyroxine are not specific laboratory results for ESRD. Leukocytes and neutrophils are types of white blood cells that indicate immune system activity and infection. Thyroxine is a thyroid hormone that regulates metabolism and growth. ESRD can affect the immune system and the thyroid function, but these are not the primary indicators of renal function.

Choice D reason: Erythrocytes, hemoglobin, and hematocrit are laboratory results that measure red blood cell count, oxygen-carrying capacity, and blood volume. ESRD can cause anemia due to reduced production of erythropoietin, a hormone that stimulates red blood cell formation in the bone marrow. Anemia can cause fatigue, pallor, shortness of breath, and chest pain. However, these are not the most significant laboratory results for ESRD.

A. Ensure that the infant's crib mattress is firm. B. Prop the infant with a pillow when in a side-lying position. C. Swaddle the infant in a blanket for sleeping. D. Place the infant in a prone position whenever possible.

Correct Answer is A

Explanation

Choice A reason: This is correct because a firm mattress reduces the risk of suffocation and rebreathing of carbon dioxide, which are associated with SIDS.

Choice B reason: This is incorrect because propping the infant with a pillow can cause the infant to slide down and suffocate or obstruct the airway.

Choice C reason: This is incorrect because swaddling the infant in a blanket can cause overheating, which is a risk factor for SIDS.

Choice D reason: This is incorrect because placing the infant in a prone position can increase the risk of SIDS by impairing gas exchange and thermoregulation.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

Correct Answer is A

Explanation

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

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