An emergency department nurse is providing handoff communication using SBAR (situation, background, assessment, recommendations) to the nurse accepting a client in the intensive care unit. The emergency department nurse reports that the client will require a suction set up for gastric tube drainage and will need an endoscopy performed. Which of the following parts of the SBAR report is the nurse communicating?

S-Situation

R-Recommendations

B-Background

A-Assessment

Answer and Explanation

The Correct Answer is B

A. S–Situation: The situation includes immediate information about why the client is being transferred or receiving care, such as current symptoms, diagnosis, or presenting complaint. It does not include upcoming procedures or equipment needs.
B. R–Recommendations: Recommendations include what actions or interventions are needed next, such as upcoming tests, procedures, or equipment setup. Mentioning the need for a suction setup and an endoscopy reflects planning for ongoing care and falls under this category.
C. B–Background: Background refers to the client's medical history, diagnosis, and events leading up to the current situation. It gives context but does not include plans for future care.
D. A–Assessment: Assessment includes clinical findings, vital signs, laboratory results, and how the client is currently presenting. It focuses on objective and subjective data, not future recommendations or equipment planning.

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Correct Answer is C

Explanation

A. "Yes, antiviral treatment will ensure that you are less contagious and do not spread influenza to others": While antiviral treatment can reduce the spread of influenza, it is not the primary reason for early initiation. The key reason for starting antiviral therapy early is to reduce the severity and duration of symptoms.
B. "No, you should wait for lab confirmation because taking antivirals for a nonviral infection can increase side effects": This is incorrect because antivirals for influenza are specific to the virus and are not used in non-viral infections. Delaying treatment could worsen symptoms.
C. "Yes, antiviral treatments are most effective when they are started within 48 hours of symptom onset": This is the most accurate statement. Antiviral drugs like oseltamivir (Tamiflu) are most effective when taken early, within the first 48 hours of symptom onset, to reduce symptom severity and duration.
D. "No, you should wait for lab confirmation before beginning antiviral treatment, to prevent resistant viruses": Early treatment is essential, and delaying therapy can lead to worsened symptoms or complications. Resistance is a concern, but it is not an immediate issue with influenza antivirals.

A. Presence of Cullen's sign B. Pain in the chest C. Lower back or groin pain D. Hunger after eating

Correct Answer is C

Explanation

A. Presence of Cullen's sign: Cullen's sign, characterized by bruising around the umbilicus, is more indicative of intraperitoneal bleeding, particularly related to conditions like pancreatitis or ruptured ectopic pregnancy, not an early sign of AAA.
B. Pain in the chest: While chest pain may occur in certain aneurysms, it is not typically associated with an abdominal aortic aneurysm (AAA), which is more likely to present with pain in the lower back or groin as the aneurysm expands.
C. Lower back or groin pain: Early manifestations of an AAA often include lower back or groin pain due to the proximity of the aorta to these areas. This pain results from the expansion or pressure on surrounding structures.
D. Hunger after eating: This is not associated with an AAA. Hunger after eating is a more general symptom and does not relate to the specific clinical presentation of an abdominal aortic aneurysm.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who has a possible abdominal aortic aneurysm (AAA). Which of the following is an early manifestation of an AAA?

Correct Answer is C

Explanation

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