An older client with a history of heart failure and 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?

Currently prescribed medications.

Fall at home as reason for admission.

Client's healthcare power of attorney.

Increasing confusion of the client.

Answer and Explanation

The Correct Answer is D

Situation: Increasing confusion of the client.

The nurse should start by providing the current situation, which is the client's increasing confusion. This is crucial information as it indicates a change in the client's condition and may require immediate attention.

Background: Fall at home as reason for admission.

Next, the nurse should provide the background information, which includes the reason for admission, in this case, the fall at home. This helps the healthcare provider understand the context and potential contributing factors to the client's current condition. Assessment: Currently prescribed medications.

After providing the background, the nurse should discuss the assessment findings. In this case, it would be appropriate to mention the client's currently prescribed medications. This information can help the healthcare provider assess for any medication-related issues or interactions that could be contributing to the client's confusion.

Recommendation: Client's healthcare power of attorney.

Lastly, the nurse should provide the recommendation, which in this case is the client's healthcare power of attorney. This information is important as it identifies the designated decision-maker for the client's healthcare decisions and can assist the healthcare provider in involving the appropriate person in the care planning process.

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Correct Answer is A

Explanation

An S3 heart sound can be a normal finding during pregnancy due to increased blood volume and changes in cardiac output. It is known as a physiological S3 and is considered a benign finding in the absence of other concerning symptoms or signs.

In this case, there is no immediate need for intervention or concern regarding the S3 heart sound. It is not necessary to prepare the client for an echocardiogram or limit the client's fluids based solely on the presence of an S3 heart sound in the absence of other significant symptoms or complications.

A. Buttered whole wheat toast and coffee. B. Sausage, poached eggs, and milk. C. Granola, strawberries, and tea. D. Oatmeal, banana, and herbal tea.

Correct Answer is D

Explanation

This breakfast selection is the most appropriate for a 16-year-old with diarrhea. Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system. It is important to avoid foods that are greasy, high in fat, or spicy, as they can worsen diarrhea symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?

Correct Answer is A

Explanation

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is D

Explanation

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)